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Gastroesophageal Reflux Disease (GERD)

Gastroesophageal Reflux Disease (GERD)



Comprehensive Presentation: Gastroesophageal Reflux Disease (GERD)

Comprehensive Presentation: Gastroesophageal Reflux Disease (GERD)



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    Gastroesophageal Reflux Disease (GERD) Gastroesophageal Reflux Disease (GERD) Presentation Transcript

    • Gastro-esophageal Reflux Disease (GERD)
    • overview
    • GERD
      Commonly known as heartburn
      Backflow of gastric and/or duodenal contents into the esophagus and past the lower esophageal sphincter (LES), without associated belching or vomiting
      Reflux may cause symptoms or pathologic changes
    • Persistent reflux can cause reflux esophagitis
      • inflammation of the esophageal mucosa
      Prognosis: varies with the underlying cause
    • Pathophysiology and Etiology
    • Normally, gastric contents don't back up into the esophagus because the LES creates enough pressure around the lower end of the esophagus to close it
      Reflux occurs when LES pressure is deficient or pressure in the stomach exceeds LES pressure
      When this happens, the LES relaxes, allowing gastric contents to regurgitate into the esophagus
    • The acidity of gastric content and amount of time in contact with esophageal mucosa are related to the degree of mucosal damage
      Inflammation and ulceration of the esophagus may result
      • esophagitis
    • Predisposing Factors
      pyloric surgery (alteration or removal of the pylorus), which allows reflux of bile or pancreatic juice
      nasogastric intubation for more than 4 days
      hiatal hernia with incompetent sphincter
      any condition or position that increases intraabdominal pressure.
    • Agents that lowers LES pressure:
      • Food
      • Alcohol
      • Cigarettes
      • Anticholinergics
      • Atropine
      • Belladonna
      • propantheline
      • Other drugs
      • Morphine
      • Diazepam
      • calcium channel blockers
      • meperidine
    • complications
    • Reflux esophagitis
      • primary complication of GERD
      Esophageal stricture
      Esophageal ulcer
      • with or without fistula formation
      Barrett’s esophagus
      • presence of columnar epithelium above the gastroesophageal junction associated with adenocarcinoma of the esophagus
    • Anemia
      • from chronic low-grade bleeding of inflamed mucosa in patients with severe reflux esophagitis
      Aspiration, may be complicated by pneumonia
      Reflux aspiration can lead to chronic pulmonary disease
    • Clinical manifestations
    • Heartburn (pyrosis)
      • most common symptom
      • typically occurring 30-60 min after meals and with reclining positions
      • complaints of spontaneous reflux (regurgitation) of sour or bitter gastric contents into the mouth
      Other typical symptoms:
      Globus (sensation of something in throat)
      Mild epigastric pain
      Nausea and/or vomiting
    • Dysphagia
      • less common symptom
      Atypical symptoms:
      • Chest pain
      • Hoarseness
      • Recurrent sore throat
      • Frequent throat clearing
      • Chronic cough
      • Dental enamel loss
      • Bronchospasm (asthma/wheezing)
      • Odynophagia (sharp substernal pain on swallowing)
    • Symptoms that may suggest other disease etiologies need further evaluation
      • atypical chest pain -rule out possible cardiac causes
      • Dysphagia rule out
      • Odynophagia cancer
      • GI bleeding or
      • shortness of breath esophageal
      • weight loss stricture
    • Diagnostic Evaluation
    • Uncomplicated GERD
      • may be diagnosed on patient history of typical symptoms
      • can visualize inflammation, lesions erosions
      • can confirm diagnosis
      • measures LES pressure and determines if esophageal peristalsis is adequate
      • should be used before patients undergo surgical treatment for reflux
      • done before a pH probe for determination of correct catheter placement
      Acid perfusion (Bernstein test)
      • onset of symptoms after ingestion of dilute hydrochloric acid and saline is considered positive
      • differentiates between cardiac and noncardiac chest pain
    • Ambulatory 24-hour pH monitoring
      • frequently performed for diagnosing GERD or reflux esophagitis
      • determines the amount of gastroesophageal acid reflux and has a 70% to 90% specificity rate
      Barium esophagography
      • use of barium with radiographic studies to diagnose mechanical and motility disorders
    • Lifestyle Modifications
    • Head of bed raised 6-8 inches (15-20 cm)
      Do not lie down for 3 to 4 hours after eating - time frame for greatest reflux
      Bland diet
      • avoid garlic, onion, peppermint, fatty foods, chocolate, coffee (including decaffeinated), citrus juices, colas, and tomato products
    • Avoid overeating
      • causes LES relaxation
      No tight-fitting clothes
      Weight control
      Smoking cessation
      Reduce alcohol
    • Pharmacologic treatment
    • Antacids
      • Reduce gastric acidity
      • Use on an as-needed basis
      • Provide symptomatic relief but do not heal esophageal lesions
      Histamine-2 (H2) receptor antagonists
      • Decrease gastric acid secretions
      • Provide symptomatic relief
      • May require lifelong therapy
      • ranitidine (Zantac)
      • cimetidine (Tagamet)
      • famotidine (Pepcid)
      • nizatidine (Axid)
    • Proton Pump Inhibitor
      • If symptoms do not respond to H2-receptor antagonist, change to a once-per-day PPI
      • blocks gastric acid secretion
      • omeprazole (Prilosec)
      • esomeprazole (Nexium)
      • pantoprazole (Protonix)
      • rabeprazole (Aciphex)
      • lansoprazole (Prevacid)
      PPIs are more effective than H2-receptor antagonists in achieving faster healing rates for erosive esophagitis
    • Drug maintenance therapy may be needed depending on the severity of disease and recurrence of symptoms after initial drug therapy is stopped
      Use the lowest effective drug dose of H2-receptor blocker or proton pump inhibitor
    • Antireflux Surgery
    • indicated for patients who do not respond to medical management
      • Upper portion of the stomach is wrapped around the distal esophagus and sutured, creating a tight LES
      • Can be performed laparoscopically
      • Combined with vagotomy-pyloroplasty if associated with gastroduodenal ulcer
      • Antireflux surgery may not eliminate the need for future pharmacologic treatment
    • Stretta procedure
      • a radiofrequency energy delivery system used to provide a thermal burn to the gastroesophageal junction
      EndoCinch procedure
      • uses endoscopic sewing device to create pleats with a series of sutures passed through adjoining folds at the proximal fundus
    • These procedures are designed to decrease reflux symptoms by tightening the lower esophageal sphincter.
      • endoscopically implanted device
      • prevents reflux of gastric acid into the throat
      • permanently placed and may eliminate the need for pharmacologic treatment of GERD symptoms
    • Nursing Diagnoses
    • Acute pain
      Deficient knowledge (diagnosis and treatment)
      Imbalanced nutrition: Less than body requirements
      Risk for aspiration
    • Key outcomes
    • The patient will:
      express feelings of comfort
      identify strategies to reduce anxiety
      express an understanding of the disorder and treatment regimen
      achieve adequate caloric and nutritional intake
      The patient won't show signs of aspiration
    • Nursing Interventions
    • Offer emotional and psychological support to help the patient cope with pain and discomfort.
      In consultation with a dietitian, develop a diet that takes the patient's food preferences into account but, at the same time, helps to minimize his reflux symptoms.
      • If the patient is obese, place him on a weight reduction diet as ordered.
    • To reduce intra-abdominal pressure, have the patient sleep in a reverse Trendelenburg position
      • Head of the bed elevated 6-12 inches (15-30 cm)
      • Avoid lying down for 3 hours after meals and eating late-night snacks
      After surgery, provide post-laparotomy care.
      Pay particular attention to the patient's respiratory status because the surgical procedure is performed close to the diaphragm.
    • Administer prescribed analgesics, oxygen, and I.V. fluids
      Monitor intake and output
      Check vital signs
      If surgery was performed using a thoracic approach, watch and record chest tube drainage
      If needed, provide chest physiotherapy
    • Patient teaching
    • Teach the patient about the causes of GERD
      Review antireflux regimen of medication, diet, and positional therapy
      Discuss recommended dietary changes.
      • Sit upright after meals & snacks
      • Eat small, frequent meals
      • Eat meals at least 2 to 3 hours before lying down
      • Avoid highly seasoned food, acidic juices, alcoholic drinks, bedtime snacks, foods high in fat because these reduce LES pressure
      Avoid situations or activities that increase intra-abdominal pressure
      • Bending
      • Coughing
      • Vigorous exercise
      • Obesity
      • Constipation
      • Wearing tight clothing
    • Refrain from using any substance that reduces sphincter control: cigarettes, alcohol, fatty foods, certain drugs
      Encourage compliance with the drug regimen
      • Review the desired drug actions and potential adverse effects
      • If taking antacid, do not take it with other medications because it will decrease their absorption
    • http://nurseRD.blogspot.com
      THANK YOU!Have a nice day : )
      - RDG