GERD and Esophageal Disorders

• The esophagus is a muscular tube, about 25 cm long, that connects the throat to the stomach, extending from the pharynx base to 4 cm below the diaphragm.
• Esophageal disorders can disrupt nutritional intake.

Esophageal Sphincters

• The upper esophageal sphincter (UES) and lower esophageal sphincter (LES) prevent food and fluid reflux.
• Esophageal contractions move food and fluids to the stomach.
• LES relaxation allows food passage into the stomach, followed by LES contraction to prevent reflux.

Esophageal Disorders

• Esophageal disorders include gastroesophageal reflux disease (GERD), hiatal hernia, and esophageal varices.

Gastroesophageal Reflux Disease (GERD)

• GERD involves gastric content and enzyme backflow into the esophagus.
• Excessive reflux, due to conditions like an incompetent LES, pyloric stenosis, hiatal hernia, high abdominal pressure, or motility issues, irritates the esophageal tissue.
• Primary treatment of GERD involves diet and lifestyle changes, progressing to medications (antacids, H2-receptor antagonists, proton pump inhibitors) and potentially surgery.
• Untreated GERD can lead to inflammation, breakdown, and complications like Barrett’s esophagus or adenocarcinoma.

Health Promotion and Disease Prevention for GERD

• Maintain a BMI below 30
• Stop smoking
• Limit or avoid alcohol and tobacco
• Eat a low-fat diet
• Avoid foods that lower LES pressure (caffeinated drinks, chocolate, nitrates, citrus fruits, alcohol)
• Avoid eating or drinking 2 hours before bed
• Avoid tight-fitting clothes
• Elevate the head of the bed 6-8 inches

GERD Risk Factors

• Obesity
• Older age
• Sleep apnea
• Nasogastric tube

Contributing Factors to GERD

• Fatty and fried foods
• Chocolate
• Caffeinated beverages
• Peppermint
• Spicy foods
• Tomatoes
• Citrus fruits
• Alcohol
• Prolonged abdominal distention
• Increased abdominal pressure from obesity, pregnancy, bending, ascites, or tight clothing
• Medications that relax the LES (theophylline, nitrates, calcium channel blockers, anticholinergics, diazepam)
• Increased gastric acid from NSAIDs or stress
• Debilitation
• Hiatal hernia
• Gastritis due to Helicobacter pylori
• Lying flat

Expected Findings in GERD

• Dyspepsia after eating certain foods or fluids and regurgitation
• Radiating pain in the neck, jaw, or back
• Feeling of a heart attack
• Pyrosis
• Odynophagia
• Pain worsening with bending, straining, or lying down
• Pain after eating, lasting 20 minutes to 2 hours
• Throat irritation, chronic cough, laryngitis, hypersalivation, bitter taste, and dysphagia in chronic GERD
• Increased flatus and burping
• Pain relief from drinking water, sitting upright, or antacids
• Dental caries
• Chest congestion and wheezing
• Manifestations occurring 4-5 times per week are considered diagnostic

Diagnostic Procedures for GERD

• Esophagogastroduodenoscopy (EGD), which can reveal esophagitis or Barrett’s epithelium.
  • Ensure gag reflex has returned before oral intake post-procedure.
  • Monitor for esophageal perforation signs (fever, pain, dyspnea, bleeding).
• Esophageal pH monitoring, which is the most accurate method for diagnosing GERD.
  • Keep a journal of foods, beverages, symptoms, and activities during the test
• Esophageal manometry, which records LES pressure and esophageal peristaltic activity.
• Barium swallow, which identifies hiatal hernias, strictures, or structural abnormalities.
  • Use cathartics post-procedure to evacuate barium and prevent fecal impaction.

Medications for GERD

• Proton Pump Inhibitors (PPIs) like pantoprazole, omeprazole, esomeprazole, rabeprazole, lansoprazole reduce gastric acid by inhibiting gastric parietal cells.
  • Monitor for electrolyte imbalances like hypomagnesemia.
  • Long-term use increases risk for community-acquired pneumonia, Clostridium difficile infections, and fractures, especially in older adults.
• Antacids like aluminum hydroxide, magnesium hydroxide, calcium carbonate, and sodium bicarbonate neutralize excess acid and increase LES pressure.
  • Ensure no contraindications with other medications.
  • Take when acid secretion is highest (1-3 hours after eating and at bedtime), separated from other medications by at least 1 hour.
• Histamine2 Receptor Antagonists like famotidine, cimetidine, and nizatidine reduce acid secretion by inhibiting histamine at gastric parietal cells.
  • Use cautiously in clients who have kidney disease.
  • Take with meals and at bedtime, separated from antacids by 1 hour.
• Prokinetics like metoclopramide increase motility of the esophagus and stomach.
  • Monitor for extrapyramidal adverse effects; Report abnormal, involuntary movements.

Therapeutic Procedures for GERD

• Stretta uses radiofrequency energy to decrease vagus nerve activity, causing LES muscle contraction.
• Fundoplication involves wrapping the stomach fundus around the esophagus to create a barrier.
  • Complications include temporary dysphagia, gas bloat syndrome, and atelectasis/pneumonia.
  • Maintain a soft diet for 1 week post-procedure.
  • Avoid foods that cause reflux, large meals, and carbonated beverages.
  • Remain upright after eating, avoid eating before bedtime, and consume four to six small meals daily.
  • Avoid tight clothing, lose weight, elevate the head of the bed, avoid heavy lifting, walk daily, and stop smoking.
  • Report fever, nausea, vomiting, severe pain, dysphagia, or persistent bloating.

Complications of GERD

• Aspiration of gastric secretions can lead to asthma exacerbations, respiratory infections, and aspiration pneumonia.
  • Place the client in semi-Fowler's position during and after meals.
  • Keep oral suction equipment at the bedside.
• Barrett’s epithelium (premalignant) and esophageal adenocarcinoma.
  • Gastric fluid reflux can cause esophagitis, leading to replacement of esophageal epithelium with premalignant or malignant tissue.
  • Review lifestyle changes to decrease gastric reflux and monitor nutritional status.

Hiatal Hernia

• A hiatal hernia is a protrusion of the stomach above the diaphragm into the thoracic cavity through the hiatus.
• Sliding hiatal hernia: the stomach and gastroesophageal junction move above the diaphragm - Paraesophageal (rolling): part of the stomach fundus moves above the diaphragm, but the gastroesophageal junction remains below the diaphragm.

Health Promotion and Disease Prevention for Hiatal Hernia

• Avoid eating immediately before bed
• Avoid foods and beverages that decrease LES pressure
• Exercise regularly
• Maintain a healthy weight
• Elevate the head of the bed
• Avoid straining
• Avoid tight clothing

Expected Findings in Hiatal Hernia

• Manifestations depend on the type of hiatal hernia and worsen after meals.
  • Sliding: heartburn, reflux, chest pain, dysphagia, belching
  • Paraesophageal: fullness, breathlessness, chest pain, worsening symptoms when reclining

Diagnostic Procedures for Hiatal Hernia

• Barium swallow with fluoroscopy allows visualization of the esophagus
  • Administer cathartics post-procedure to evacuate barium and prevent fecal impaction
• Esophagogastroduodenoscopy (EGD) allows visualization of the esophagus and the gastric lining
  • Ensure gag reflex returns before giving oral fluids
• CT scan of the chest with contrast visualizes the esophagus and stomach
  • Check for iodine allergies if using IV contrast
  • Encourage fluids post-procedure to promote dye excretion and minimize risk of renal injury; Monitor BUN/creatinine

Medications for Hiatal Hernia

• Proton Pump Inhibitors (PPIs) like pantoprazole, omeprazole, esomeprazole, rabeprazole, lansoprazole reduce gastric acid by inhibiting gastric parietal cells.
  • Watch for electrolyte imbalances like hypomagnesemia.
  • Long-term use has been linked to community-acquired pneumonia and Clostridium difficile infections.
  • Long-term use also raises the risk of fractures, especially in older adults.
• Antacids like aluminum hydroxide, magnesium hydroxide, calcium carbonate, and sodium bicarbonate neutralize excess acid and increase LES pressure.
  • Ensure there are no contraindications with other prescribed medications.
  • Evaluate kidney function if the client is taking magnesium hydroxide.
  • Take antacids when acid secretion is the highest (1 to 3 hr after eating and at bedtime), and separate from other medications by at least 1 hr.

Therapeutic Procedures for Hiatal Hernia

• Fundoplication involves reinforcing the LES by wrapping a portion of the stomach fundus around the distal esophagus.
  • Laparoscopic Nissen fundoplication is minimally invasive with fewer complications.
  • Elevate the head of the bed to promote lung expansion.
  • Support the incision during movement and coughing.
  • Consume a soft diet for the first week postoperatively.
  • Avoid carbonated beverages and heavy lifting.
  • Ambulate.
  • Complications include temporary dysphagia, gas bloat syndrome, and atelectasis/pneumonia.

Complications of Hiatal Hernia

• Volvulus: twisting of the esophagus and/or stomach
• Obstruction (paraesophageal hernia): blockage of food in the herniated portion of the stomach
• Strangulation (paraesophageal hernia): compression of the blood vessels to the herniated portion of the stomach
• Iron-deficiency anemia (paraesophageal hernia): resulting from bleeding into the gastric mucosa due to obstruction

Esophageal Varices

• Esophageal varices are fragile, swollen blood vessels in the lower esophagus submucosa that can extend higher or into the stomach.
• They result from portal hypertension, usually from cirrhosis of the liver. Hemorrhage is a medical emergency with high mortality; recurrence is common.

Health Promotion and Disease Prevention for Esophageal Varices

• Avoid alcohol consumption.

Risk Factors for Esophageal Varices

• Portal hypertension from impaired liver circulation causes collateral circulation and varices.
• Primary risk factors include alcoholic cirrhosis and viral hepatitis.
• Older adults are more vulnerable to bleeding due to reduced liver and immune function, and cardiac conditions.

Expected Findings in Esophageal Varices

• Clients can be asymptomatic until varices bleed
• Hematemesis
• Melena
• General physical and mental deterioration
• Activities that precipitate bleeding include the Valsalva maneuver, lifting heavy objects, coughing, sneezing, and alcohol consumption.

Physical Findings in Bleeding Esophageal Varices

• Shock
• Hypotension
• Tachycardia
• Cool, clammy skin

Laboratory Tests for Esophageal Varices

• Liver function tests indicate a liver disorder.
• Hemoglobin and hematocrit tests can indicate anemia.
• Elevated blood ammonia level can indicate liver disease.

Diagnostic Procedures for Esophageal Varices

• Endoscopy allows for therapeutic interventions.
  • Administer pre-procedure sedation.
  • After the procedure, monitor vital signs and take measures to prevent aspiration, such as confirming the gag reflex before offering oral fluids.

Nursing Care for Esophageal Varices

• If bleeding is suspected, establish IV access, monitor vital signs and hematocrit, type and cross-match for blood transfusions, and monitor for overt and occult bleeding.

Medications for Esophageal Varices

• Nonselective Beta Blockers like propranolol decrease heart rate and hepatic venous pressure, used prophylactically.
• Vasoconstrictors include octreotide, which decreases bleeding without affecting blood pressure, and vasopressin, constricting esophageal and gastric veins and reducing portal pressure.
• Vasopressin should not be given to clients who have coronary artery disease due to resultant coronary constriction. Potent vasoconstriction can also reduce peripheral and cerebral circulation.
• Monitor for fluid retention and hyponatremia, as vasopressin has an antidiuretic effect.

Therapeutic Procedures for Esophageal Varices

• Endoscopic Variceal Ligation (EVL) involves rubber-banding varices to cut off circulation, leading to necrosis.
  • Monitor vital signs and prevent aspiration post-procedure.
  • Complications include superficial ulceration, dysphagia, temporary chest discomfort, and esophageal strictures (rare).
• Endoscopic Sclerotherapy injects a sclerosing agent into varices, causing thrombosis.
  • Monitor vital signs and prevent aspiration.
  • Give antacids, H2-receptor blockers, or PPIs post-procedure.
  • Complications include bleeding, perforation, aspiration pneumonia, and esophageal stricture.
• Transjugular Intrahepatic Portal-Systemic Shunt (TIPS) lowers portal pressure when EVL and medications fail.
  • Monitor vital signs, bleeding, and coagulation studies; Keep the head of the bed elevated.
  • Complications include bleeding, sepsis, heart failure, organ perforation, and liver failure.
• Surgical Interventions -Bypass procedures create shunts to bypass the liver, decreasing portal hypertension. -Monitor for increased liver dysfunction or encephalopathy. -Monitor nasogastric tube secretions for bleeding. -Monitor PT, aPTT, platelets, and INR.

Complication of Esophageal Varices

• Hypovolemic Shock due to hemorrhage.
  • Observe for manifestations of hemorrhage and shock (tachycardia, hypotension).
  • Monitor vital signs, Hgb, Hct, and coagulation studies.
  • Support therapeutic procedures to stop and control bleeding.

Test your knowledge of GERD and esophageal disorders. This quiz covers reflux mechanisms, esophageal length, dietary recommendations, and complications. Questions address diagnosis, management, and nursing interventions.