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Gastroesophageal Reflux Disease (GERD)


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Comprehensive Presentation: Gastroesophageal Reflux Disease (GERD)

Published in: Health & Medicine
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Gastroesophageal Reflux Disease (GERD)

  1. 1. Gastro-esophageal Reflux Disease (GERD)<br />
  2. 2. overview<br />
  3. 3.
  4. 4. GERD<br />Commonly known as heartburn <br />Backflow of gastric and/or duodenal contents into the esophagus and past the lower esophageal sphincter (LES), without associated belching or vomiting<br />Reflux may cause symptoms or pathologic changes<br />
  5. 5.
  6. 6. Persistent reflux can cause reflux esophagitis<br /><ul><li>inflammation of the esophageal mucosa</li></ul>Prognosis: varies with the underlying cause<br />
  7. 7.
  8. 8.
  9. 9. Pathophysiology and Etiology<br />
  10. 10.
  11. 11. 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<br />Reflux occurs when LES pressure is deficient or pressure in the stomach exceeds LES pressure<br />When this happens, the LES relaxes, allowing gastric contents to regurgitate into the esophagus<br />
  12. 12.
  13. 13. The acidity of gastric content and amount of time in contact with esophageal mucosa are related to the degree of mucosal damage<br />Inflammation and ulceration of the esophagus may result<br /><ul><li>esophagitis</li></li></ul><li>Predisposing Factors<br />pyloric surgery (alteration or removal of the pylorus), which allows reflux of bile or pancreatic juice<br />nasogastric intubation for more than 4 days<br />hiatal hernia with incompetent sphincter<br />any condition or position that increases intraabdominal pressure.<br />
  14. 14. Agents that lowers LES pressure: <br /><ul><li>Food
  15. 15. Alcohol
  16. 16. Cigarettes
  17. 17. Anticholinergics
  18. 18. Atropine
  19. 19. Belladonna
  20. 20. propantheline
  21. 21. Other drugs
  22. 22. Morphine
  23. 23. Diazepam
  24. 24. calcium channel blockers
  25. 25. meperidine</li></li></ul><li>complications<br />
  26. 26. Reflux esophagitis<br /><ul><li>primary complication of GERD</li></ul>Esophageal stricture<br />Esophageal ulcer<br /><ul><li>with or without fistula formation</li></ul>Barrett’s esophagus<br /><ul><li>presence of columnar epithelium above the gastroesophageal junction associated with adenocarcinoma of the esophagus</li></li></ul><li>Anemia<br /><ul><li>from chronic low-grade bleeding of inflamed mucosa in patients with severe reflux esophagitis</li></ul>Aspiration, may be complicated by pneumonia<br />Reflux aspiration can lead to chronic pulmonary disease<br />
  27. 27.
  28. 28. Clinical manifestations<br />
  29. 29. Heartburn (pyrosis)<br /><ul><li>most common symptom
  30. 30. typically occurring 30-60 min after meals and with reclining positions
  31. 31. complaints of spontaneous reflux (regurgitation) of sour or bitter gastric contents into the mouth</li></ul>Other typical symptoms:<br />Globus (sensation of something in throat)<br />Mild epigastric pain<br />Dyspepsia<br />Nausea and/or vomiting<br />
  32. 32.
  33. 33. Dysphagia<br /><ul><li>less common symptom</li></ul>Atypical symptoms:<br /><ul><li>Chest pain
  34. 34. Hoarseness
  35. 35. Recurrent sore throat
  36. 36. Frequent throat clearing
  37. 37. Chronic cough
  38. 38. Dental enamel loss
  39. 39. Bronchospasm (asthma/wheezing)
  40. 40. Odynophagia (sharp substernal pain on swallowing)</li></li></ul><li>Symptoms that may suggest other disease etiologies need further evaluation<br /><ul><li>atypical chest pain -rule out possible cardiac causes
  41. 41. Dysphagia rule out
  42. 42. Odynophagia cancer
  43. 43. GI bleeding or
  44. 44. shortness of breath esophageal
  45. 45. weight loss stricture</li></li></ul><li>Diagnostic Evaluation<br />
  46. 46. Uncomplicated GERD<br /><ul><li>may be diagnosed on patient history of typical symptoms</li></ul>Endoscopy<br /><ul><li>can visualize inflammation, lesions erosions</li></ul>Biopsy <br /><ul><li>can confirm diagnosis</li></ul>Esophagealmanometry<br /><ul><li>measures LES pressure and determines if esophageal peristalsis is adequate</li></li></ul><li><ul><li>should be used before patients undergo surgical treatment for reflux
  47. 47. done before a pH probe for determination of correct catheter placement</li></ul>Acid perfusion (Bernstein test)<br /><ul><li>onset of symptoms after ingestion of dilute hydrochloric acid and saline is considered positive
  48. 48. differentiates between cardiac and noncardiac chest pain</li></li></ul><li>Ambulatory 24-hour pH monitoring <br /><ul><li>frequently performed for diagnosing GERD or reflux esophagitis
  49. 49. determines the amount of gastroesophageal acid reflux and has a 70% to 90% specificity rate</li></ul>Barium esophagography<br /><ul><li>use of barium with radiographic studies to diagnose mechanical and motility disorders</li></li></ul><li>MANAGEMENT<br />
  50. 50. Lifestyle Modifications<br />
  51. 51. Head of bed raised 6-8 inches (15-20 cm)<br />Do not lie down for 3 to 4 hours after eating - time frame for greatest reflux<br />Bland diet<br /><ul><li>avoid garlic, onion, peppermint, fatty foods, chocolate, coffee (including decaffeinated), citrus juices, colas, and tomato products</li></li></ul><li>Avoid overeating<br /><ul><li>causes LES relaxation</li></ul>No tight-fitting clothes<br />Weight control<br />Smoking cessation<br />Reduce alcohol<br />
  52. 52. Pharmacologic treatment<br />
  53. 53. Antacids<br /><ul><li>Reduce gastric acidity
  54. 54. Use on an as-needed basis
  55. 55. Provide symptomatic relief but do not heal esophageal lesions</li></ul>Histamine-2 (H2) receptor antagonists<br /><ul><li>Decrease gastric acid secretions
  56. 56. Provide symptomatic relief
  57. 57. May require lifelong therapy
  58. 58. ranitidine (Zantac)
  59. 59. cimetidine (Tagamet)
  60. 60. famotidine (Pepcid)
  61. 61. nizatidine (Axid)</li></li></ul><li>
  62. 62. Proton Pump Inhibitor <br /><ul><li>If symptoms do not respond to H2-receptor antagonist, change to a once-per-day PPI
  63. 63. blocks gastric acid secretion
  64. 64. omeprazole (Prilosec)
  65. 65. esomeprazole (Nexium)
  66. 66. pantoprazole (Protonix)
  67. 67. rabeprazole (Aciphex)
  68. 68. lansoprazole (Prevacid)</li></ul>PPIs are more effective than H2-receptor antagonists in achieving faster healing rates for erosive esophagitis<br />
  69. 69. Drug maintenance therapy may be needed depending on the severity of disease and recurrence of symptoms after initial drug therapy is stopped<br />Use the lowest effective drug dose of H2-receptor blocker or proton pump inhibitor<br />
  70. 70. Antireflux Surgery<br />
  71. 71. indicated for patients who do not respond to medical management<br />Nissenfundoplication<br /><ul><li>Upper portion of the stomach is wrapped around the distal esophagus and sutured, creating a tight LES
  72. 72. Can be performed laparoscopically
  73. 73. Combined with vagotomy-pyloroplasty if associated with gastroduodenal ulcer
  74. 74. Antireflux surgery may not eliminate the need for future pharmacologic treatment</li></li></ul><li>
  76. 76. Stretta procedure<br /><ul><li>a radiofrequency energy delivery system used to provide a thermal burn to the gastroesophageal junction</li></ul>EndoCinch procedure <br /><ul><li>uses endoscopic sewing device to create pleats with a series of sutures passed through adjoining folds at the proximal fundus</li></li></ul><li>These procedures are designed to decrease reflux symptoms by tightening the lower esophageal sphincter.<br />Enteryx<br /><ul><li>endoscopically implanted device
  77. 77. prevents reflux of gastric acid into the throat
  78. 78. permanently placed and may eliminate the need for pharmacologic treatment of GERD symptoms</li></li></ul><li>NURSING MANAGEMENT<br />
  79. 79. Nursing Diagnoses<br />
  80. 80. Acute pain<br />Anxiety <br />Deficient knowledge (diagnosis and treatment)<br />Imbalanced nutrition: Less than body requirements<br />Risk for aspiration<br />
  81. 81. Key outcomes<br />
  82. 82. The patient will:<br />express feelings of comfort<br />identify strategies to reduce anxiety<br />express an understanding of the disorder and treatment regimen<br />achieve adequate caloric and nutritional intake<br />The patient won't show signs of aspiration<br />
  83. 83. Nursing Interventions<br />
  84. 84. Offer emotional and psychological support to help the patient cope with pain and discomfort.<br />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. <br /><ul><li>If the patient is obese, place him on a weight reduction diet as ordered.</li></li></ul><li>To reduce intra-abdominal pressure, have the patient sleep in a reverse Trendelenburg position<br /><ul><li>Head of the bed elevated 6-12 inches (15-30 cm)
  85. 85. Avoid lying down for 3 hours after meals and eating late-night snacks</li></ul>After surgery, provide post-laparotomy care. <br />Pay particular attention to the patient's respiratory status because the surgical procedure is performed close to the diaphragm. <br />
  86. 86. Administer prescribed analgesics, oxygen, and I.V. fluids<br />Monitor intake and output<br />Check vital signs<br />If surgery was performed using a thoracic approach, watch and record chest tube drainage<br />If needed, provide chest physiotherapy<br />
  87. 87. Patient teaching<br />
  88. 88. Teach the patient about the causes of GERD<br />Review antireflux regimen of medication, diet, and positional therapy<br />Discuss recommended dietary changes. <br /><ul><li>Sit upright after meals & snacks
  89. 89. Eat small, frequent meals
  90. 90. Eat meals at least 2 to 3 hours before lying down</li></li></ul><li><ul><li>Avoid highly seasoned food, acidic juices, alcoholic drinks, bedtime snacks, foods high in fat because these reduce LES pressure</li></ul>Avoid situations or activities that increase intra-abdominal pressure<br /><ul><li>Bending
  91. 91. Coughing
  92. 92. Vigorous exercise
  93. 93. Obesity
  94. 94. Constipation
  95. 95. Wearing tight clothing</li></li></ul><li>Refrain from using any substance that reduces sphincter control: cigarettes, alcohol, fatty foods, certain drugs<br />Encourage compliance with the drug regimen<br /><ul><li>Review the desired drug actions and potential adverse effects
  96. 96. If taking antacid, do not take it with other medications because it will decrease their absorption</li></li></ul><li><br /><br /><br />THANK YOU!Have a nice day : )<br />- RDG<br />