In this slideshare we will se about GERD , i hope it helps u . Gastroesophageal reflux diseases (GERD) is not a disease but a heterogenous syndrome resulting from esophageal reflux. Most cases are attributed to the inappropriate relaxation of lower esophageal sphincter (LES) in response to unknown stimulus.

1. GASTROESOPHAGEAL REFLUX DISEASE (GERD)
Introduction:-
Gastroesophageal reflux diseases (GERD) is not a disease but a heterogenous syndrome resulting
from esophageal reflux. Most cases are attributed to the inappropriate relaxation of lower esophageal
sphincter (LES) in response to unknown stimulus.
Etiology :-
The common cause of GERD is Haital Hernia, the presence of which displaces the LES
into the thorax and, number of environmental and physical factors have been
identified that appear to influence the tone and contractility of the LES and these
may play an etiological role in some cases of GERD.
The pressure of the LES is lowered by
-fatty acids
-chocolate
-peppermint

2. -cola
-coffee
- tea
-nicotine
- alcohol
-drugs such as calcium channel blockers, the theophyl-line, and possible non-steroidal
anti-inflammatory drugs (NSAID),
-elevated levels of estrogen and progestrone; and that conditions that elevate
intra-abdominal pressure such as obesity, pregnancy or heavy lifting.
Pathophysiology
There are two zones of high pressure, one at each end of the esophagus, normally
prevent the reflux of gastric contents. The zones maintain a constant pressure and
relax only during swallowing. Although they are termed as LES, they are not really
distinct anatomical structures. Esophageal reflux occurs when either gastric volume or
intra-abdominal pressure is elevated or when LES tone is decreased. Periodic reflux
occurs normally in most persons and is usually asymptomatic. The normal physiologic

3. response to occasional reflux is immediate swallowing one or more rapid swallows
induce peristatic contractions to clear the reflux and neutralize the acid with
bicarbonate-rich saliva. However, the esophagus has only a limited ability to withstand
the damaging effects of acid reflux and GERD will develop when frequent episodes of
reflux breakdown the mucosal barrier and
initiate an inflammatory response.
The degree of esophageal inflammation related to. the number, duration and acidity or
alkalinity of the reflux episodes. The effectiveness and efficiency of esophageal
clearance also are important. Esophageal clearance is particularly important at night
when the swallowing rate and salivation decrease by two thirds and recumbent position
interferes with clearance. An inflammed esophageal gradually loses its ability to clear
reflexed material quickly and efficiently, and the duration of each episode gradually
lengthens. Hyperemia and erosion occur in the face of chronic inflammation. Minor
capillary bleeding is common, although frank bleeding is rare. Repeated episodes of
inflammation and healing can gradually produce a change in the epithelial tissue, which
makes it more resistant to acid. Overtime, fibrotic tissue changes can also result in
esophageal stricture, which can progressively impair normal swallowing.

4. Clinical Manifestations:-
• Heartburn is caused by irritation of the esophagus by the gastric secretion. It is a burning,
tight sensation that appears intermittently beneath the lower sternum and spreads upward
to the throat or jaw. It occurs following ingestion of substances that decrease LES pressure.
It is relieved with milk, alkaline substance or water.
• Pulmonary symptoms including wheezing, hoarseness, coughing, (nocturnal cough),
dyspnea are secondary to microaspiration of gastric contents into the pulmonary system.
• Gastric symptoms including early satiety, prostating bloating, nausea, and vomiting, are
related to gastric stasis.
• Regurgitation is effortless return of material fromstomach into esophagus or mouth,
oftenly descri-bed as hot, bitter or sour liquid coming into the throat or mouth. This taste is
perceived in the pharynx.

5. • Water brash a reflex, hypersecretion that does not have a bitter taste.
• Frequent belching and flatulence and feeling of lump in the throat or food stopping.
• Dysphagia difficulty in swallowing.
• Odynophagia painfull swallowing.
• Bleeching.
In addition GERD patients may experience complication of respiratory system —
bronchospasm, laryngospasm, circopharyngeal system and other
complications include:
– Esophageal stricture (due to repeated episodes),
– Esophageal metaplasia (Barretts esophagus),
– Pneumonia (due to aspiration of gastric contents to
pulmonary system).

6. Management of GERD :-
Patients with GERD are rarely admitted to the acute care setting unless they require surgery or experience
serious complications. The problem is self-managed in the out-patient setting. The goal of treatment is to
decrease the incidence of reflux and eliminate the symptoms.
The diagnostic studies are performed to determine
the causes are:
• Barium swallow for determining the protrusion of upper part of the stomach (gastric cardia).
• Radionuclide tests to detect reflux of gastric contents and the rate of esophageal clearance.
• Esophagoscopy—to detect the incompetence of LES and the extent of inflammation, potential
scarring and strictures.
• Biopsy and cytologic tests to differentiate hiatal hernia, carcinoma and Barrett’s esophagus.
• Esophageal motility (manometry) studies to measure pressure in the esophagus and GES.
• pH monitoring for presence of acid or alkaline.

7. Pharmacologic management
It is focussed on improving LES function, increasing esophageal clearance, decreasing
volume or acidity reflux, and protecting esophageal mucosa.
• Antacids are used to relieve heartburn by their neutralizing effect on hydrochloric
acid. (For example, Gelucil, Maalox, Mylanta).
• Antacids plus alginic acid (Gaviscon) are used to neutralize gastric acid and reacts with
sodium bicarbonate and forms a viscous solution that floats to the surface of the gastric
contents and coats the esophagus acting on mechanical barrier to reflux.
When client is an antacid and alginic acid, the nurse should evaluate the effectiveness of the
drug, monitor frequency of use and monitor for constipation or diarrhea and assist patient
to adjust product use as needed.
•Anti-secretory drugs, i.e. histamine (H2) receptors are used to reduce the gastric acid
secretion and supports tissue healing which include ranitidine, cimetidine, famotidine,
nizaoidine. During use of these, the nurse should instruct patient to take drugs with meals
if ordered at intervals, and monitor for common side effects, fatigue, headache, diarrhea.

8. • Prokinetic drugs are used to increase LES pressure and enhance gastrointestinal motility,
which includes cisapride (Propulsid). Here the nurse has to instruct patient to take drug no
more than 15 minutes before eating and monitor levels of drugs that require useful titration.
• Proton pump inhabitors are used to inhabit enzyme
system of gastric parietal cells and suppress gastric
acid secretions by more than 90 percent. Here the nurse has to instruct patient to take the
drug before meals and monitor for side effects, abdominal cramping, headache, diarrhea.
For example,
omeprazole, lansoprazole are PP inhibitors.
Surgical management:-
Antireflux surgery is usually
performed in patient with severe GERD who do not
respond to aggressive medical management which
includes:
• Nissen fundoplication
• Hill gastropexy
• Belseys fundoplication

9. • Antireflux prosthesis.
Nursing Management:-
● The nurse by using nursing process, assesses the client on the basis of clinical
manifestation stated above and take body weight, ascultate for signs for reflux
aspirates and observe for hoarseness or wheezing-day or night.
● The nursing diagnosis are made from analysis of patient’s data.
● The diagnoses are not limited to pain and knowledge deficit.
● The objectives of nursing care will include reports, minimal or no episodes of heart
burn and list diet and life style changes.
● GERD is typically managed by using a combination of drug therapy, diet, and life style
modification and assisting surgical therapies if needed.

10. ● The nurse discusses the medication regimen with the patient and ensures that written
information about the safe use and expected side effects of all meciations is provided,
and administer the ordered medication and observe for response and side effects;
Antacids that contain aluminium tend to cause constipation, where as those contain
magnesium tend to cause diarrhea.
● Several of the antacids are combination of aluminium and magnesium designed to
minimize these effects.
● If the patient is taking bethenechol (cholenergic) side effects to observe for urinary
urgency, increased salivation, abdominal cramping with darrhea, nausea, vomiting,
and hypotension
● Side effects of metadopramide (dopamine antogonist) a prokinetic drug includes
restlessness, anxiety and insomnia.
● Side effects of sucralfate (acid-protective) include drowsiness, dizziness, nausea,
vomiting, constipation, urticaria and rash.
● When nursing the patient with GERD the nurse has to use the following.
■ Diet and lifestyle modifications to manage the same:

11. • In relation to diet patient are encouraged to:
– Eat 4-6 small meals daily.
– Follow a low-fat, adequate protein diet.
– Reduce intake of chocolate, tea and all foods and beverages that contain caffeine.
– Limit or eliminate alcohol intake.
– Eat slowly and chew food thoroughly.
– Avoid evening snacking and do not eat for 2-3 hours before bed time.
– Remain upright for 1-2 hours after meals when possible and never eat in bed.
– Avoid any food that directly produces heart burn.

12. – Reduce over all body weight if indicated.
• The nurse has to promote lifestyle of the patient by encouraging to:
– Eliminate or drastically reduce smoking.
– Avoid evening smoking, and never smoke in bed.
– Avoid constrictive clothing over the abdomen.
– Avoid activities that involve straining, heavy lifting or working in a bent-over position.
– Elevate the head of the bed at least 6-8 inches for sleep using wooden blocks or a thick
foam wedge.
– Never sleep flat in bed.

13. • For prevention of GERD, the nurse should use the
following teaching guidelines for patient and
family.
– Explain the rationale for a high-protein, low-fat diet.
– Encourage the patient to eat small, frequent meals to prevent gastric distention.
– Explain the rationale for avoiding alcohol, smoking (causes an almost immediate, marked
decrease in LES pressure) and beverage that contains caffeine.
– Instruct the patient not to lie down for 2 to 3 hours after eating, wear tight clothing
around the waist, or bend over (especially after eating).
– Encourage the patient to sleep with head of bed elevated on 4-6 inch blocks (gravity
fosters esophageal emptying)
- Teach regarding medication including rationale for their use and common side effects.

14. – Discuss strategies for weight reduction if appropriate.
– Encourage patient and family to share concerns about lifestyle changes and living with a
chronicproblem.
● Made by priyanshu verma
Bsc. Nursing 3rd year student
Reference:- Essentials of Medical Surgical Nursing by
" BT Basavanthappa "