Gastroesophageal Reflux Disease GERD Chapter 42 Copyright 2014

Description of GERD • Common problem • Chronic manifestation of mucosal damage • Caused

Etiology and Pathophysiology • No one single cause • Results when • Defenses of

Etiology and Pathophysiology • Reflux of HCl acid and pepsin secretions cause irritation and

Etiology and Pathophysiology of GERD Copyright © 2014 by Mosby, an imprint of Elsevier

Case Study i. Stockphotos/Thinkstock • M. C. , a 20 -year-old man, complains of

Etiology and Pathophysiology • Predisposing factors • Hiatal hernia • Incompetent lower esophageal sphincter

Etiology and Pathophysiology • Incompetent LES • Primary factor in GERD • Results in

Etiology and Pathophysiology • Obesity is a risk factor • Pregnant women are at

Clinical Manifestations • Symptoms of GERD • Heartburn (pyrosis) • Most common clinical manifestation

Clinical Manifestations • Symptoms of GERD • Dyspepsia • Pain or discomfort centered in

Case Study i. Stockphotos/Thinkstock • M. C. is 5 feet, 10 inches tall and

Case Study i. Stockphotos/Thinkstock • Besides chest pain after meals, M. C. complains of

Clinical Manifestations • Most individuals have mild symptoms • Heartburn after a meal •

Clinical Manifestations • Health care provider should evaluate • Heartburn occurring more than once

Clinical Manifestations • Heartburn occurs • Following ingestion of food or drugs that ↓

Case Study i. Stockphotos/Thinkstock • M. C. also has a history of asthma. •

Clinical Manifestations • Individual may also report respiratory symptoms • Wheezing • Coughing •

Clinical Manifestations • Otolaryngologic symptoms include • Hoarseness • Sore throat • Lump in

Clinical Manifestations • GERD-related chest pain • Described as burning, squeezing, or radiating to

Case Study i. Stockphotos/Thinkstock • M. C. is scheduled for an endoscopy to evaluate

Complications • Related to direct local effects of gastric acid on esophageal mucosa •

Esophagitis Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Complications • Barrett’s esophagus (esophageal metaplasia) • Replacement of normal squamous epithelium with columnar

Complications • Barrett’s esophagus • Diagnosed in 5% to 15% of patients with chronic

Complications • Respiratory • Due to irritation of upper airway by secretions • Cough

Complications • Respiratory • Potential for asthma, bronchitis, and pneumonia • Dental erosion •

Diagnostic Studies • History and physical examination • Barium swallow • Can detect protrusion

Diagnostic Studies • Biopsy and cytologic specimens • Differentiate cancer from Barrett’s esophagus •

Diagnostic Studies • Radionuclide tests • Detect reflux of gastric contents • Demonstrate of

Diagnostic Studies • Monitoring p. H • Laboratory or 24 -hour ambulatory • Determine

Case Study • M. C. is being discharged today. • He expresses concern about

Collaborative Care • Lifestyle modifications • Avoid triggers • Nutritional therapy • Decrease high-fat

Collaborative Care • Nutritional therapy • Avoid chocolate, peppermint, caffeine, tomato products, orange juice

Case Study i. Stockphotos/Thinkstock • M. C. is prescribed the following medications for home:

Collaborative Care • Drug therapy • Proton pump inhibitors (PPIs) • Promote esophageal healing

Drug Alert • Proton pump inhibitors • Long-term use or high doses of PPIs

Collaborative Care • Drug therapy • Histamine-2 receptor (H 2 R) blockers • Decrease

Collaborative Care • Drug therapy • Acid protective • Used for cytoprotective properties •

Collaborative Care • Drug therapy • Cholinergic • Increase LES pressure • Improve esophageal

Collaborative Care • Drug therapy • Prokinetic drugs • Promote gastric emptying • Reduce

Collaborative Care • Drug therapy • Antacids • Quick but short-lived relief • Neutralize

Collaborative Care • Surgical therapy • When necessary • Failure of conservative therapy •

Nissen Fundoplication Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Collaborative Care • LINX Reflux Management System • Titanium beads with a magnetic core

Collaborative Care • Endoscopic therapy • Endoscopic mucosal resection • Photodynamic therapy • Cryotherapy

Nursing Management • Elevation of head of bed 30 degrees • Not lying down

Nursing Management • Evaluating effectiveness of medications • Observing for side effects of medications

Nursing Management • Avoidance of factors that cause reflux • Stop smoking • Avoid

Nursing Management • Stress reduction techniques • Weight reduction, if appropriate • Small, frequent

Case Study i. Stockphotos/Thinkstock • M. C. has repeated exacerbations of esophagitis, despite maintaining

Nursing Management • Postoperative care • Focus • Prevention of respiratory complications • Maintenance

Nursing Management • Postoperative care • Respiratory assessment • Respiratory rate/rhythm • Pulse rate/rhythm

Nursing Management • Postoperative care • Deep breathing techniques • Accurate I/O • Observing

Nursing Management • Postoperative care • When peristalsis returns, only fluids given initially •

Case Study • M. C. ’s surgery was done laparoscopically. • He has progressed

Nursing Management • Postoperative care • First month after surgery, patient may report mild

Audience Response Question After the nurse teaches a patient with gastroesophageal reflux disease (GERD)

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Description of GERD • Common problem • Chronic manifestation of mucosal damage • Caused by reflux of gastric contents into lower esophagus • Not a disease, but a syndrome Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Etiology and Pathophysiology • No one single cause • Results when • Defenses of lower esophagus are overwhelmed by reflux of gastric contents into esophagus Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Etiology and Pathophysiology • Reflux of HCl acid and pepsin secretions cause irritation and inflammation • Intestinal proteolytic enzymes and bile salts add to irritation Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Case Study i. Stockphotos/Thinkstock • M. C. , a 20 -year-old man, complains of loss of appetite and occasional lower sternal chest pain 30– 60 minutes after meals. • He says that symptoms began about 6 months ago. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Etiology and Pathophysiology • Predisposing factors • Hiatal hernia • Incompetent lower esophageal sphincter (LES) • Antireflux barrier • Decreased esophageal clearance • Decreased gastric emptying Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Etiology and Pathophysiology • Incompetent LES • Primary factor in GERD • Results in ↓ pressure in distal portion of esophagus • Gastric contents move from stomach to esophagus • Can be due to certain foods (caffeine, chocolate) and drugs (anticholinergics) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Etiology and Pathophysiology • Obesity is a risk factor • Pregnant women are at increased risk • Cigarette and cigar smoking can contribute to GERD • Hiatal hernia is a common cause of GERD Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Clinical Manifestations • Symptoms of GERD • Heartburn (pyrosis) • Most common clinical manifestation • Burning, tight sensation felt beneath the lower sternum and spreading upward to throat or jaw • Felt intermittently Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Clinical Manifestations • Symptoms of GERD • Dyspepsia • Pain or discomfort centered in upper abdomen • Regurgitation • Described as hot, bitter, or sour liquid coming into throat or mouth • Hypersalivation may also be reported Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Case Study i. Stockphotos/Thinkstock • Besides chest pain after meals, M. C. complains of heartburn several times a week and occasionally brings up a bitter liquid into his mouth. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Clinical Manifestations • Health care provider should evaluate • Heartburn occurring more than once a week, rated as severe, or occurring at night and waking patient • Older adults with recent onset of heartburn Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Clinical Manifestations • GERD-related chest pain • Described as burning, squeezing, or radiating to back, neck, jaw, or arms • Can mimic angina • More common in older adults with GERD • Relieved with antacids Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Case Study i. Stockphotos/Thinkstock • M. C. is scheduled for an endoscopy to evaluate his symptoms. • The results indicate he has acute esophagitis as well as Barrett’s esophagus. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Complications • Related to direct local effects of gastric acid on esophageal mucosa • Esophagitis • Inflammation of esophagus • Frequent complication • Repeated exposure: esophageal stricture • Resulting in dysphagia Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Complications • Barrett’s esophagus (esophageal metaplasia) • Replacement of normal squamous epithelium with columnar epithelium • Precancerous lesion • Thought to be primarily due to GERD Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Complications • Barrett’s esophagus • Diagnosed in 5% to 15% of patients with chronic reflux • Signs and symptoms: none to perforation • Must be monitored every 2– 3 years by endoscopy Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Complications • Respiratory • Potential for asthma, bronchitis, and pneumonia • Dental erosion • From acid reflux into mouth • Especially posterior teeth Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Diagnostic Studies • History and physical examination • Barium swallow • Can detect protrusion of gastric fundus • Upper GI endoscopy • Useful in assessing LES competence, degree of inflammation, scarring, strictures Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Diagnostic Studies • Biopsy and cytologic specimens • Differentiate cancer from Barrett’s esophagus • Esophageal manometric (motility) studies • Measure pressure in esophagus and LES Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Case Study • M. C. is being discharged today. • He expresses concern about what lifestyle changes may be necessary to prevent recurrences or complications. i. Stockphotos/Thinkstock Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Collaborative Care • Lifestyle modifications • Avoid triggers • Nutritional therapy • Decrease high-fat foods • Take fluids between rather than with meals • Avoid milk products at night • Avoid late-night snacking or meals Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Collaborative Care • Nutritional therapy • Avoid chocolate, peppermint, caffeine, tomato products, orange juice • Weight reduction therapy • Chewing gum and oral lozenges can increase saliva production and help patients with mild symptoms Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Case Study i. Stockphotos/Thinkstock • M. C. is prescribed the following medications for home: • Esomeprazole (Nexium), 20 mg daily • Ranitidine (Zantac), 150 mg twice a day Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Collaborative Care • Drug therapy • Proton pump inhibitors (PPIs) • Promote esophageal healing in 80% to 90% of patients • Decrease incidence of esophageal strictures • Example: omeprazole (Prilosec) • Headache: Most common side effect Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Drug Alert • Proton pump inhibitors • Long-term use or high doses of PPIs may increase the risk of fractures of hip, wrist, and spine • Associated with increased risk of C. difficile infection in hospitalized patients Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Collaborative Care • Drug therapy • Histamine-2 receptor (H 2 R) blockers • Decrease secretion of HCl acid • Reduce symptoms and promote esophageal healing in 50% of patients • Example: cimetidine (Tagamet) • Side effects uncommon Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Collaborative Care • Drug therapy • Cholinergic • Increase LES pressure • Improve esophageal emptying • Increase gastric emptying • Example: bethanechol (Urecholine) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Collaborative Care • Drug therapy • Prokinetic drugs • Promote gastric emptying • Reduce risk of gastric acid reflux • Example: metoclopramide (Reglan) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Collaborative Care • Drug therapy • Antacids • Quick but short-lived relief • Neutralize HCl acid • Taken 1– 3 hours after meals/at bedtime • Example: Maalox, Mylanta Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Collaborative Care • Surgical therapy • When necessary • Failure of conservative therapy • Medication intolerance • Barrett’s metaplasia • Esophageal stricture and stenosis • Chronic esophagitis • Nissen and Toupet fundoplications Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Collaborative Care • LINX Reflux Management System • Titanium beads with a magnetic core strung together and implanted laparoscopically into LES • Under resting, nonswallowing conditions, the ring tightens • When individual swallows, the ring opens Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Case Study i. Stockphotos/Thinkstock • M. C. has repeated exacerbations of esophagitis, despite maintaining his medication regimen and diet. • His doctor refers him to a surgeon for evaluation. • Surgeon recommends a Nissen fundoplication. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Management • Postoperative care • Focus • Prevention of respiratory complications • Maintenance of fluid/electrolyte balance • Prevention of infection Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Management • Postoperative care • Respiratory assessment • Respiratory rate/rhythm • Pulse rate/rhythm • Signs of pneumothorax • Dyspnea • Chest pain • Cyanosis Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Management • Postoperative care • Deep breathing techniques • Accurate I/O • Observing for fluid/electrolyte imbalance • Pain medication • Medications to prevent nausea/vomiting Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Management • Postoperative care • When peristalsis returns, only fluids given initially • Solids added gradually • Normal diet gradually resumed • Patient must avoid gas-forming foods and must chew foods thoroughly Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Case Study • M. C. ’s surgery was done laparoscopically. • He has progressed to a soft diet and is able to ambulate independently. • He is being discharged to home today. i. Stockphotos/Thinkstock Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Management • Postoperative care • First month after surgery, patient may report mild dysphagia; should resolve after edema subsides • Patient should report persistent symptoms such as heartburn and regurgitation Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Audience Response Question After the nurse teaches a patient with gastroesophageal reflux disease (GERD) about recommended dietary modifications, which statement by the patient indicates that the teaching has been effective? a. “I can have a glass of low-fat milk at bedtime. ” b. “I will have to eliminate all spicy foods from my diet. ” c. “I will have to use herbal teas instead of caffeinated drinks. ” d. “I should keep something in my stomach all the time to neutralize the excess acids. ” Copyright © 2014 by Mosby, an imprint of Elsevier Inc.