Esophagus Disorders 2 PDF

Management of Patients With Esophageal Disorders Chapter 39 1 LEARNING OBJECTIVES On completion of this chapter, the learner will be able to: Apply the nursing process as a framework for care of patient...

Management of Patients With Esophageal Disorders Chapter 39 1 LEARNING OBJECTIVES On completion of this chapter, the learner will be able to: Apply the nursing process as a framework for care of patients with various conditions of the esophagus. Identify various disorders of the esophagus and their clinical manifestations and management. 2  DISORDERS OF THE ESOPHAGUS The esophagus is a mucus-lined, muscular tube that carries food from the mouth to the stomach. The upper esophageal sphincter, also called the hypopharyngeal sphincter, is located at the junction of the pharynx and the esophagus. The lower esophageal sphincter, also called the gastroesophageal sphincter or cardiac sphincter, is located at the junction of the esophagus and the stomach. 3 4  Achalasia Is absent or ineffective peristalsis of the distal esophagus accompanied by failure of the esophageal sphincter to relax in response to swallowing. Narrowing of the esophagus just above the stomach results in a gradually increasing dilation of the esophagus in the upper chest. 5 6  Achalasia Clinical manifestations: -Dysphagia (solids and liquids). -A sensation of food sticking in the lower portion of the esophagus. -As the condition progresses, food is commonly regurgitated. -The patient may also report non-cardiac chest or epigastric pain and pyrosis (heartburn) that may or may not be associated with eating. -These symptoms mirror those of GERD, and patients are often misdiagnosed and treated for GERD 7 Achalasia Assessment & Diagnostic Findings: -X-ray: esophageal dilation above the narrowing at the gastroesophageal junction. -Barium swallow, computed tomography (CT) scan of the chest, and endoscopy may be used for diagnosis. 8  Achalasia Management: -The patient is instructed to eat slowly and to drink fluids with meals. -Injection of botulinum toxin (Botox) into quadrants of the esophagus via endoscopy has been helpful because it inhibits the contraction of smooth muscle. -Pneumatic dilation: a high success rate; long-term results are variable, perforation is a potential complication -Achalasia may be treated surgically by esophagomyotomy, called a Heller myotomy, which involves cutting the esophageal muscle fibers. 9 10 11 12  Esophageal Spasm Has three types: 1. In jackhammer esophagus, referred to as hypercontractile esophagus, spasms occur on more than 20% of swallows at a very high amplitude, duration, and length. 2. In diffuse esophagus spasm (DES), the spasms are normal in amplitude, but are uncoordinated, move quickly, and occur at various places in the esophagus at once. 3. Type III achalasia is characterized by lower esophageal sphincter obstruction with esophageal spasms 13 Esophageal Spasm Clinical Manifestations: All three forms of esophageal spasm are characterized by: -Dysphagia -Pyrosis -Regurgitation -Chest pain similar to that of coronary artery spasm. 14  Esophageal Spasm Assessment and Diagnostic Findings: Esophageal manometry, which measures the motility and internal pressure of the esophagus, can test for irregular and high-amplitude spasms. 15 Esophageal Spasm Management: - First-line therapy includes calcium channel blockers and nitrates to reduce the pressure and amplitude of contractions. -Like the treatment for achalasia, botulinum toxin may be used -Proton pump inhibitors (PPIs) may also be indicated, especially if symptoms of GERD are present -Small, frequent feedings and a soft diet are usually recommended -If conservative therapies do not provide relief, Heller myotomy or per-oral endoscopic myotomy (POEM) 16 may be tried  Hiatal Hernia The opening in the diaphragm through which the esophagus passes becomes enlarged. The part of the upper stomach moves up into the lower portion of the thorax. Hiatal hernia occurs more often in women than in men. 17 Hiatal Hernia There are two main types of hiatal hernias: 1. Sliding (type I): -Occurs when the upper stomach and the gastroesophageal junction are displaced upward and slide in and out of the thorax. -About 95% of patients with esophageal hiatal hernia have a sliding hernia. 2. A paraesophageal (type II) -Occurs when all or part of the stomach pushes through the diaphragm beside the esophagus. -Type IV has the greatest herniation, with other intra-abdominal viscera such as the colon, omentum, or small bowel present in the hernia sac that is displaced 18 19 20  21 Hiatal Hernia Clinical Manifestations: -The patient with a sliding hernia: pyrosis, regurgitation, and dysphagia, but many patients are asymptomatic. -Large hiatal hernias: intolerance to food, nausea, and vomiting. -Sliding hiatal hernias are commonly associated with GERD. -Hemorrhage, obstruction, volvulus (bowel obstruction caused by a twist in the intestines and supporting mesentery) can occur with any type of hernia but are more common with paraesophageal hernia 22  23 Hiatal Hernia Assessment & diagnostic findings: - Diagnosis is typically confirmed by x-ray studies; barium swallow; esophagogastroduodenoscopy (EGD). Management: -Small frequent foods 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 -To elevate the head of the bed on (10- to 20-cm) blocks to prevent the hernia from sliding upward. 24  Hiatal Hernia Management: cont… -Surgical hernia repair is indicated in patients who are symptomatic, is typically to relieve GERD. -Up to 50% of patients may experience early postoperative dysphagia, the nurse advances the diet slowly from liquids to solids, while managing nausea and vomiting, tracking nutritional intake, and monitoring weight. 25 Gastroesophageal Reflux Disease (GERD) Common disorder marked by backflow of gastric or duodenal contents into the esophagus that causes trouble some symptoms and/or mucosal injury to the esophagus. Excessive reflux may occur because of an incompetent lower esophageal sphincter, pyloric stenosis, hiatal hernia, or a motility disorder. GERD is associated with tobacco use, coffee drinking, alcohol consumption, and gastric infection with Helicobacter pylori. 26  Gastroesophageal Reflux Disease (GERD) Clinical Manifestations: -Pyrosis (heartburn, specifically more commonly described as a burning sensation in the esophagus), dyspepsia (indigestion), regurgitation, dysphagia or odynophagia, hypersalivation, and esophagitis. -GERD can result in dental erosion, ulcerations in the pharynx and esophagus, laryngeal damage, esophageal strictures, adenocarcinoma, and pulmonary complications 27 Gastroesophageal Reflux Disease (GERD) Assessment and Diagnostic Findings: -The patient’s history aids in obtaining an accurate diagnosis. -Diagnostic testing may include ambulatory pH monitoring, which is the gold standard for the diagnosis of GERD, or a PPI trial. -Diagnostic testing may include an endoscopy or barium swallow to evaluate damage to the esophageal mucosa. 28  Manometry and Electrophysiologic Studies Manometry and electrophysiologic studies are methods for evaluating patients with GI motility disorders Esophageal manometry is used to detect motility disorders of the esophagus and the upper and lower esophageal sphincter The patient must refrain from eating or drinking for 8 to 12 hours before the test A pressure-sensitive catheter is inserted through the nose and is connected to a transducer and a video recorder. The patient then swallows small amounts of water while the resultant pressure changes are recorded. Evaluation of a patient for GERD typically includes esophageal manometry 29 Gastroesophageal Reflux Disease (GERD) Management: -Management begins with educating the patient to avoid situations that decrease lower esophageal sphincter pressure or cause esophageal irritation. -Lifestyle modifications include tobacco cessation, limiting alcohol, weight loss, elevating the head of the bed, avoiding eating before bed, and altering the diet -Medications: (Antacids/Acid neutralizing agents, Histamine-2, receptor antagonists, Proton pump inhibitors (PPIs) First-line drugs used. -Surgical intervention may be necessary. 30  The nursing care to patients with Esophagus disorders Impaired nutritional intake associated with difficulty swallowing Risk for aspiration associated with difficulty swallowing or tube feeding Acute pain associated with difficulty swallowing, ingestion of an abrasive agent, tumor, or frequent episodes of gastric reflux Lack of knowledge about the esophageal disorder, diagnostic studies, medical management, surgical intervention, and rehabilitation 31 Cancer of the Esophagus Adenocarcinoma is more common among African Americans Men more than women Esophageal cancer can be of two cell types: adenocarcinoma and squamous cell carcinoma Risk factors for esophageal cancer: -Chronic esophageal irritation or GERD -Ingestion of alcohol -Tobacco -Ingestion of hot liquids or foods -Nutritional deficiencies 32  Clinical Manifestations Dysphagia with solid foods A sensation of a mass in the throat Painful swallowing Substernal pain or fullness Later, regurgitation of undigested food with halitosis and hiccups As the tumor grows and the obstruction becomes nearly complete, even liquids cannot pass into the stomach. Regurgitation of food and saliva occurs Hemorrhage Progressive loss of weight 33 Assessment and Diagnostic Findings A CT scan of chest and abdomen A PET scan may also help detect metastasis Endoscopic ultrasound is used to determine whether the cancer has spread to the lymph nodes 34  Medical Management At an early stage: treatment goals may be directed toward cure In late stages, making relief of symptoms the only reasonable goal of therapy Treatment may include surgery, radiation, chemotherapy, or a combination of these modalities, depending on the type of cancer cell, the extent of the disease, and the patient’s condition A standard treatment plan: preoperative combination chemotherapy and radiation therapy for 4 to 6 weeks, followed by a period of no medical intervention for 4 weeks, and, finally, surgical resection of the esophagus Standard surgical management includes esophagectomy with removal of the tumor 35 36  37 Nursing Management Ordinary pre-operative preparation Post-operative care The patient is placed in a low fowler position Later in a fowler position The patient is observed carefully for regurgitation and dyspnea Chest physiotherapy is avoided due to the risk of aspiration. The patient is also monitored for a postoperative chylothorax (accumulation of chyle/lymphatic fluid in the pleural cavity), which would require pleural drainage 38 Nursing Management Esophageal anastomotic leak is managed by facilitating adequate drainage, initiating broad- spectrum antibiotics NG tube is inserted and taped in place. Once feeding begins, the nurse encourages the patient to swallow small sips of water The diet is advanced as tolerated to a soft, mechanical diet After each meal, the patient remains upright for at least 2 hours to allow the food to move through the GI tract 39 THANK YOU 40