GASTROINTESTINAL DISORDERS – Gastroesophageal Reflux Disease (GERD) (Etiology, Signs and Symptoms, Pathophysiology, Diagnostic Evaluation, Management and Nursing Intervention)

Gastroesophageal reflux (GER) occurs when stomach contents flow back up into the esophagus. GER is also called acid reflux or acid regurgitation which is characterized by heartburn, burning feeling in the midchest, behind the breastbone, or in the upper part of the abdomen

Gastroesophageal reflux disease results when the lower esophageal sphincter becomes weak or relaxes when it should not, causing stomach contents to rise up into the esophagus called GERD

Etiology


  • Obesity
  • Pregnancy
  • Certain medications, such as asthma medications, calcium channel blockers, and many antihistamines, pain-killers, sedatives, and antidepressants
  • Smoking, or inhaling second-hand smoke
  • Use of spicy foods
  • Sudden falling to sleep after meal
  • Congenital weakness of LES


 

Signs and Symptoms


  • Dry, chronic cough
  • Wheezing
  • Asthma and recurrent pneumonia
  • Nausea
  • Vomiting
  • Sore throat, hoarseness, or laryngitis – swelling and irritations of the voice box
  • Difficulty swallowing or painful swallowing
  • Pain in the chest or the upper part of the abdomen
  • Dental erosion and bad breath


 

Pathophysiology

Abnormal exposure of the esophagus to gastric contents occurs by loss of the barrier between the esophagus and stomach ---- this barrier is comprised of two components, the lower esophageal sphincter (LES) and the diaphragm muscles that surround the esophagus ---- over time, the LES can become permanently destroyed ---- results in a short-length or low resting pressure, allowing gastric contents to reflux up into the esophagus ---- as a result, the diaphragm muscles surrounding the esophagus can become lax, allowing the formation of a hiatal hernia ---- this allows the stomach to partially migrate into the chest and put the LES at a mechanical disadvantage

Diagnostic Evaluation

  • Upper GI series: during this procedure, the person will stand or sit in front of an X-ray machine and drink barium, a chalky liquid. Barium coats the esophagus, stomach, and small intestine so the radiologist and gastroenterologist can see theses organs shapes more clearly on X-rays. The barium shows problems related to GERD, such as hiatal hernias
  • Upper endoscopy, also known as an esophagogastroduodenoscopy: this procedure involves using an endoscope, a small, flexible tube with a light, to see the upper GI tract. The person may receive a liquid anesthetic that is gargled or sprayed on the back of the throat. After the person receives sedation, the gastroenterologist carefully feeds an endoscope through the mouth and down the esophagus, then into the stomach and duodenum. A small camera mounted on the endoscope transmits a video image to a monitor, allowing close examination of the intestinal lining
  • Esophageal pH monitoring: the most accurate test to detect acid reflux, esophageal pH monitoring measures the amount of liquid or acid in the esophagus. A gastroenterologist will pass a thin tube, called a nasogastric probe, through the person’s nose or mouth to the stomach. The gastroenterologist will then pull the tube back into the esophagus, where it will be taped to the person’s cheek and remain in place for 24 hours. The end of the tube in the esophagus has a small probe to measure when and how much liquid or acid come up into the esophagus. The other end of the tube, attached to a monitor outside of the body, shows the measurements taken
  • Esophageal manometry: esophageal manometry measures muscle contractions in the esophagus


 

Management

Lifestyle Changes


  • Losing weight
  • Wearing loose-fitting clothing around the stomach area
  • Remaining upright for 3 hours after meals
  • Raising the head of the bed 6 to 8 inches by securing wood blocks under the bedposts
  • Avoiding smoking


 

Pharmacological Management


  • Antacids, which include over-the-counter medications, recommend relieving heartburns and other mild GERD syndrome
  • H2 blockers, such as cimetidine, famotidine and ranitidine, decrease acid production
  • PPIs include omeprazole, pantoprazole
  • Prokinetics, which include bethanechol and metoclopramide, help make the stomach empty faster
  • Antibiotics, including one called erythromycin, have been shown in improve gastric emptying


 

Surgical Management


  • Fundoplication is an operation to sew the top of the stomach around the esophagus to add pressure to the lower end of the esophagus and reduce reflux. A surgeon performs fundoplication using a laparoscope, a thin tube with a tiny video camera attached used to look inside the body
  • Endoscopic techniques, such as endoscopic sewing and radiofrequency. Endoscopic sewing uses small stitches to tighten the sphincter muscle. Radiofrequency creates heat lesions that help tighten the sphincter muscle


 

Nursing Intervention


  • Develop a diet for the patient that takes his food preferences into account while helping to minimize reflux symptoms
  • To reduce intra-abdominal pressure, encourage the patient to sleep in reverse Trendelenburg’s position with the head of the bed elevated 6” to 12”.
  • Encourage the patient to avoid lying down immediately after meals and late-night snacks
  • Monitor for complication of the disease and of surgery, if appropriate
  • Teach the patient about the causes of gastroesophageal reflux, and review his antireflux regimen for medication, diet, and positional therapy
  • Discuss the recommended dietary changes
  • Instruct the patient to avoid situations or activities that increase intra-abdominal pressure
  • Encourage the patient’s compliance with his drug regimen
  • Administer the prescribed medications
  • Avoid aspirin, which is an anticoagulant, and foods and beverages that contain acid-enhancing caffeine (colas, tea, coffee, chocolate), along with decaffeinated coffee
  • Encourage patient to eat meals at regular intervals in a relaxed atmosphere, obtain regular weights and encourage dietary modifications
  • Encourage relaxation techniques
  • Assess what patient wants to know about the disease, and evaluate level of anxiety, encourage patient to express fears only and without criticism
  • Explain diagnostic tests and administering medications on schedule
  • Interact in a relaxing manner, help in identifying stressors, and explain effective coping techniques and relaxation methods
  • Encourage family to participate in care, and give emotional support
  • Assess the faintness or dizziness and nausea, before or with bleeding, test stool for occult or gross blood, and monitor vital signs frequently (tachycardia, hypotension, and tachypnea)
  • Insert an indwelling urinary catheter and monitor intake and output, insert and maintain an IV line for infusing fluid and blood
  • Monitor oxygen saturation and administering oxygen therapy
  • Place the patient in the recumbent position with the legs elevated to prevent hypotension, or place the patient on the left side to prevent aspiration from vomiting
  • Treat hypovolemic shock as indicated

 

GASTROINTESTINAL DISORDERS – Gastroesophageal Reflux Disease (GERD) (Etiology, Signs and Symptoms, Pathophysiology, Diagnostic Evaluation, Management and Nursing Intervention) 

GASTROINTESTINAL DISORDERS – Gastroesophageal Reflux Disease (GERD) (Etiology, Signs and Symptoms, Pathophysiology, Diagnostic Evaluation, Management and Nursing Intervention)