Gastroesophageal Reflux Disease (GERD)

Gastroesophageal Reflux Disease (GERD)

• Backflow of stomach or gastric/duodenal contents into the esophagus causes this common disorder and esophageal mucosal injury
• Incompetent lower esophageal sphincter is a cause, and means the junction between the esophagus and stomach's sphincter is open, enabling reflux
• Pyloric stenosis causes GERD because the stomach contents cannot move towards the intestine
• Hiatal hernia causes GERD because a part of the stomach protrudes into the diaphragm
• Abnormal peristaltic movement means the motility disorder causes GERD
• Other risk factors include increased instances with aging and irritable bowel syndromes
• Obstructive airway disorders such as asthma, COPD, and lung hyperinflation are causes
• Barrett's esophagus can cause gas stimulation resulting in GERD, and the esophagus looks like stomach rugae
• Peptic Ulcer Disease (PUD) and angina can be causes
• Irritants like tobacco, H. pylori infection, coffee, and alcohol are factors

GERD Clinical Manifestations

• Pyrosis (heartburn) involves a burning sensation in the esophagus that is not cardiac in nature
• Regurgitation is a whole mark of symptoms
• Dyspepsia is a feeling of indigestion
• Dysphagia or odynophagia is difficulty in swallowing
• Hypersalivation indicates excessive saliva production
• Esophagitis is inflammation of the esophageal lining

GERD Diagnosis and Treatment

• GERD is similar to a heart attack
• Dental erosions, ulceration in the pharynx and esophagus, laryngeal damage, esophageal strictures, adenocarcinoma, and pulmonary complications like aspiration can occur without treatment
• The diagnosis involves the patient's history
• Ambulatory pH monitoring involves placing a transnasal catheter to insert a wireless capsule for approximately 24 hours to quantify reflux
• Endoscopy or barium swallow is the gold standard to evaluate esophageal mucosal damage and rule out strictures and hiatal hernia
• Patient education includes avoiding secretion to decrease lower esophageal sphincter pressure
• Stop smoking and limit alcohol intake
• Obesity can contribute to GERD therefore weight Loss is vital Maintain normal body weight
• Follow a low-fat diet, and avoid caffeine, peppermint, and carbonated beverages
• Head of the bed should be elevated to prevent aspirations
• Refrain from eating or drinking 2 hours before bed, and also tight-fitting clothes
• Antacids neutralize gastric acids, but can lead to infection of Clostridium difficile due to normal gastric flora loss
• H2 blockers helps manage GERD
• Famotidine, cimetidine, and proton pump inhibitors can contribute by decreasing gastric acid production
• Pantoprazole, omeprazole, metoclopramide or plasil (prokinetic agents) accelerate gastric emptying to promote stomach contents' passage in the intestine

Open Laparoscopic Nissen Fundoplication

• It involves wrapping a portion of the gastric fundus around the esophagus's sphincter area to tighten the junction between esophagus and stomach and prevent reflux

Esophageal Diverticulum

• The out-pouching of mucosa and submucosa protrudes through a weak portion of the esophagus muscles
• A Esophageal Diverticulum may occur in 3 areas of the esophagus
• The first area is in the upper part of esophagus (pharyngoesophageal)
• The second area is mid-esophageal
• The third area is in the lower part of the esophagus and is epiphrenic diverticula

Zenker Diverticulum

• Most common type of diverticulum
• It is located in the pharyngoesophageal area of the esophagus and located posterior to the pharynx middle of the neck
• It is caused by a dysfunctional sphincter that fails to open (pulsion diverticulum)
• An increased pressure forces the mucosa and submucosa to protrude and herniate through throat muscles
• Common in people older than 60

Clinical Manifestation of Esophageal & Zenker Diverticulum

• Dysphagia (swallowing difficulties) is apparent
• Fullness in the neck because of the presents of food
• The pouch becomes full of food or liquid
• Belching, regurgitation of undigested food
• Patient displays coughing and Halitosis
• Sour taste in the mouth indicates retained food has decomposed

Diagnosing and Managing Esophageal & Zenker Diverticulum

• A barium swallow determines the exact measure and location of the diverticulum
• Esophagoscopy is contraindicated because perforation of the diverticulum is possible
• Mediatinitis wherein there is inflammation of tissues and organs in the mediastinum separated from the lungs
• For endoscopic septostomy, dissection of the pouch is a factor
• Peroral Endoscopic Myotomy (POEM) involves dissecting only the cricopharyngeal muscle leaving the pouch sac unchanged
• Open surgery entails diverticulectomy
• Extra care prevents trauma to the carotid artery and internal jugular veins
• Management includes facilitating gastric emptying post-op to prevent ileus, and NGT may be inserted cautiously with imaging
• Observe for the incision for evidence of leakage and fistula development
• Food and fluids are withheld until x-ray studies show no leakage at the surgical site
• Diet starts with liquids, that will be increased as tolerated
• Surgery on epiphrenic and mid-esophageal diverticula happens only if symptoms worsen
• Treatment consists of myotomy
• Intramural diverticula regress after the esophageal stricture expands

Hiatal Hernia

• An opening in the diaphragm which esophagus passes becomes enlarged where part of the stomach hernias towards the lower portion
• There are 2 Hiatal Hernia types

Sliding Type 1

• Upper portion to the stomachs and the gastroesophageal junction is displaced upward
• Between 90% and 95% of 3406 patients with esophageal hiatal hernia have a sliding hernia

Paraoesophageal

• All or part of the stomach pushes through the diaphragm
• Type IV has the greatest herniation with intra-abdominal viscera
• Other abdominal structures move up through the diaphragm

Clinical Presentation of Hiatal Hernia

• One may have pyrosis (heartburn), regurgitation, and dysphagia, but many patients are asymptomatic
• The patient may present with vague symptoms of intermittent epigastric pain or fullness after eating
• Large hiatal hernias may lead to intolerance to food, nausea, and vomiting
• Sliding hiatal hernias are commonly associated with GERD

Hiatal Hernia Complications include

• Hemorrhage, obstruction, volvulus (bowel obstruction caused by a twist in the intestines and supporting mesentery), and strangulation can occur with any type of hernia and is common with paraoesophageal hernia

Hiatal Hernia Diagnosis and Management

• Confirmed via with x-ray studies and determining the extent of the hernia with barium Swallow
• Esophagogastroduodenoscopy (EGD) lets viewers visualize the stomach
• Esophageal manometry measures the pressure and constriction of the esophagus during the swallowing
• The managment includes frequent small feedings
• Elevate head of the bed 4-8 inches
• Do not recline for 1 hour after eating
• The repair is indicated in symptomatic patients to relieve GERD symptoms
• Approach during is based on current guidelines
• NOTE: A surgical repair is indicated with hiatal hernia, particularly when exhibiting no symptoms

Toupet or Nissen Fundoplication

• These are considered as current guidelines, and applies to patients with spleen trauma
• During procedure a barrier is formed between esophagus and stomach

Post-Operation

• Ensure a progressive liquid to solid diet
• Manage N&V, nutritional intake
• Monitor weight with belching, abdominal distention, and epigastric pain issues
• Encourage eating slowly and fluids with meals
• Advise client to keep taking meds prescribed
• In the event of any difficulties, the nurse may seek advice from the doctor
• These must be reported to the doctor ASAP
• The operation may be necessary in specific circumstances if there is obstruction or suspected strangulation

Achalasia

• This is from absent or ineffective peristalsis of the distal esophagus accompanied by failure of the esophageal sphincter to relax when swallowing takes place
• There is gradual narrowing and increased dilation of the esophagus
• Occurs in people between 20-40 years old + 60-70 years old

Manifestation of Achalasia

• Dysphagia (hallmark is difficulty with solid food)
• Patient has a sensation of food sticking in the lower portion of the esophagus
• As the condition progresses, food is commonly regurgitated
• The patient displays a burning and noncardiac chest

Achalasia Diagnosis

• Check the esophagus using various methods
• An X-ray shows esophageal dilation above the narrowing at the lower gastroesophageal sphincter, which resembles a bird's beak
• Endoscopy may be used for diagnosis, but high-resolution manometry is confirmatory

Achalasia Interventions

• Eat slowly and drink fluids with meals
• Botulinum toxin injection, Pneumatic dilation, Esophagomyotomy (Heller myotomy), POEM

Gastritis

• This is from the irritation of the gastric
• It may be acute or chronic

Acute Gastritis

• Is errosive, and from local irritants, particularly use of aspirin, NSAIDs, corticosteroids, alcohol consumptions + therapy
• Infection of the gastric, which is non-erosive (H. pylori)
• Most severe form is a alkali ingestion that can severely affect the membrane

Chronic Gastritis

• Classified due to what caused it such as H. pylori
• Can lead to peptic ulcer diseases and cancer of the stomach/gastric adenocarcinoma
• Can also result to gastric mucosa associated lymphoid tissue lymphoma

Other Causes

• Long-Term Drug Therapy – NSAIDs, aspirin which may lead to chemical, gastric injury or gastropathy
• Reflux of duodenal contents after gastric surgery
• Autoimmune disorder can lead to chronic gastric as well

Pathology and Manifestation

• Characterized by a disruption of the mucosal barrier from
• Fatigue + Heartburn and Pyrosis follow
• Epigastric Pain, Anorexia, N&V + Hiccups

Diagnosis and Management

• Endoscopy & Biopsy used
• Refrain from alcohol and food with a non-irritating diet of IV fluids
• During an EMERGENCY, treat with Supportive therapy is needed
• Modify and promote good sleep
• Relieving symptoms
• Treat H.pylori
• Monitor with ice chips or liquid for any symptom or complication, then introduce asap
• Discourage stimulant and food irritants.

Peptic Ulcer Disaese

• Excavation of mucosa in an area of the GIT
• Peptic ulcer is often multiple
• Ulcer location can be on Pylorus + Duodenal or Esophageal

Pre Dispositions

• Often between the ages of 30-60/ NSAIDS + Smoking/ H.Pylori
• Can occur due to blood type, autoimmune deficiency
• Can be tested with aUrea breath test and G I scope

Peptic Symptoms

• Vomiting + Pain or Discomfort
• Check vitals such as blood presssure
• Test for stool and signs of other stomach disress or symptoms

Peptic Treament

• Give anti biotics for bacterial infection
• Decrease acid
• Encourage regular small meals while avoiding stimulants. + NSAIDS
• Note and monitor any signs of pain, and bleeding in any part of stomach
• Maintain ideal diet