Esophageal Disorders Flashcards
(55 cards)
1
Q
what is GERD?
A
- Common condition characterized by gastric content and enzyme backflow into the esophagus
- Some backflow of stomach contents is normal, but when the reflux is excessive, the corrosive fluids irritate the esophageal tissue–>causes a delay in their clearance–>exposes esophageal tissue to the acidic fluids–>irritation
2
Q
what causes there to be excessive reflux?
A
- Incompetent LES
- Pyloric stenosis
- Hiatal hernia
- Excessive intra-abdominal or intragastric pressure
- Motility problems
3
Q
primary tx for GERD
A
- Diet and lifestyle changes
- Medication: antacids, H2 receptor antagonists, PPIs
- Surgery
4
Q
GERD: health promotion and dz prevention
A
- Maintain a BMI <30
- Stop smoking
- Limit or avoid alcohol and tobacco
- Eat a low fat diet
- Avoid foods that lower the LES pressure
- Avoid eating/drinking 2 hr before bed
- Avoid tight fitting clothes
- Elevate the HOB 6-8 in
5
Q
GERD: risk factors
A
- Obesity
- Older age: delayed gastric emptying and weakened LES tone
- Sleep apnea
- NG tube
6
Q
GERD: contributing factors
A
- Excessive ingestion of foods that relax the LES include fatty & fried foods, chocolate, caffeinated beverages, peppermint, spicy foods, tomatoes, citrus fruits, alcohol
- Prolonged or frequent abdominal distention from overeating or delayed emptying
- Inc abdominal pressure from obesity, pregnancy, bending at the waist, ascites, tight clothing at the waist
- Meds that relax the LES: theophylline, nitrates, CCBs, anticholinergics, diazepam
- Inc gastric acids from meds (NSAIDs) or stress
- Debilitation resulting in weakened LES tone
- Hiatal hernia (LES displacement into the thorax w/ delayed esophageal clearance)
- Lying flat
7
Q
GERD: expected findings
A
- Classic report of dyspepsia after eating an offending food/fluid and regurgitation
- Radiating pain (neck, jaw, back)
- Report of a feeling of having a heart attack
- Pyrosis
- Dyspepsia (indigestion)
- Dysphagia or odynophagia (pain on swallowing)
- Pain that worsens w/ position (bending, straining, laying down)
- Pain that occurs after eating and lasts 20 min to 2 hours
- Throat irritation (chronic cough, laryngitis), hypersalivation, bitter taste in mouth (from regurg)
- Chronic GERD can lead to dysphagia
- Inc flatus and eructation (burping)
- Pain is relieved (almost immediately) by drinking water, sitting upright, or taking antacids
- Manifestations occurring 4-5 times/week on consistent basis
- Tooth erosion
8
Q
what are the diagnostic procedures for GERD?
A
- EGD
- esophageal pH monitoring
- esophageal manometry
- barium swallow
9
Q
GERD: EGD
A
- Done under moderate sedation
- Looks for tissue damage and to dilate strictures in the esophagus
- Esophageal lining should be pink, but usually red w/ persistent GERD
- Biopsies will be done to determine if high grade dysplasia (HGD) is present
- HGD is evidenced by squamous mucosa of the esophagus replaced by columnar epithelium (which are the cells seen in stomach/intestines)
- When HGD is found, 30% inc in developing cancer
- HGD is evidenced by squamous mucosa of the esophagus replaced by columnar epithelium (which are the cells seen in stomach/intestines)
- Allows for visualization of esophagus revealing esophagitis or Barrett’s epithelium (premalignant cells)
- Nursing Actions:
- Verify gag response has returned prior to providing fluids or food
10
Q
GERD: esophageal pH monitoring
A
- Small catheter is placed thru the nose and into the distal esophagus, or a small capsule is attached to the esophageal wall during endoscopy
- pH readings are taken in relation to food, position, activity for 24-48 hours
- Most accurate way to diagnose GERD
- Helpful for clients with atypical manifestations
- Nursing Actions:
- Instruct the client to keep a journal of foods, beverages consumed, symptoms, and activity during the test period
11
Q
GERD: esophageal manometry
A
- Records LES pressure and peristaltic activity of the esophagus
- Client swallows 3 small tubes, and pressure readings and pH levels are tested
12
Q
GERD: barium swallow
A
- Identifies a hiatal hernia, strictures, or structural abnormalities which would contribute to or cause GERD
- Nursing Actions:
- Instruct the client to use cathartics to evacuate the barium from the GI tract following the procedure
- Failure to eliminate the barium places client at risk for fecal impaction
- Instruct the client to use cathartics to evacuate the barium from the GI tract following the procedure
13
Q
list classes of meds for GERD
A
- PPIs
- Antacids
- H2 Receptor Antagonists
- Prokinetics
14
Q
GERD: PPIs
A
- PPIs: pantoprazole, omeprazole, esomeprazole, rabeprazole, lansoprazole
- Reduce gastric acid by inhibiting the cellular pump of the gastric parietal cells necessary for gastric acid secretion
- Nursing Considerations:
- Monitor for electrolyte imbalances and hypoglycemia in clients who have DM
- Long term use has been related to the development of community acquired pneumonia and c. diff infections
- Client education:
- Long term use of PPIs places the client at risk for frxs, especially in older adults
15
Q
GERD: Antacids
A
- aluminum hydroxide, magnesium hydroxide, calcium carbonate, sodium bicarb
- Neutralize excess acid and increase LES pressure
- Nursing Considerations:
- Ensure there are no contraindications w/ other meds (levothyroxine)
- Evaluate kidney function in clients taking magnesium hydroxide
- Client Edu:
- Instruct client to take when acid secretion is the highest (1-3 hours after eating and at bedtime), and to separate other meds by at least 1 hour
16
Q
GERD: H2 Receptor Antagonistis
A
- ranitidine, famotidine, nizatidine
- Reduce the secretion of acid
- Onset is longer than antacids, but effect has a longer duration
- Nursing Considerations:
- Use cautiously in clients w/ kidney dz
- Client Edu:
- Take w/ meals & at bedtime
- Separate dosages from antacids (1 hour before or after taking antacid)
17
Q
GERD: Prokinetics
A
- metoclopramide
- Inc motility of esophagus and stomach
- Nursing Considerations:
- Monitor the client taking metoclopramide for extrapyramidal SEs
- Client Edu:
- Instruct client to report abnormal, involuntary movemen
18
Q
GERD: Stretta
A
- type of therapeutic procedure
- procedure uses radiofrequency energy, applied by an endoscope, to decrease vagus nerve activity
- Causes LES muscle tissue to contract & tighten
19
Q
GERD: fundoplication
A
- therapeutic procedure for GERD
- can be indicated for clients who fail to respond to other treatments
- Fundus of the stomach is wrapped around and behind the esophagus thru a laparoscope to create a physical barrier
- Nursing Considerations:
- Complications:
- temporary dysphagia: monitor for aspiration
- Gas bloat syndrome: difficulty belching to relieve distention
- atelectasis/pneumonia: monitor respiratory function
- Complications:
- Client Edu:
- Diet:
- Avoid offending foods
- Avoid large meals
- Remain upright after eating
- Avoid eating before bedtime
- Consume 4-6 small meals throughout the day
- Lifestyle:
- Avoid clothing that is tight fitting around the abdomen
- Lose weight
- Elevate HOB 6-8 in
- Sleep on right side
- Diet:
20
Q
list complications of GERD
A
- aspiration of gastric secretion
- Barrett’s epithelium or esophageal carcinoma
21
Q
GERD: aspiration of gastric secretion
A
- Causes: reflux of gastric fluids into esophagus can be aspirated into trachea
- Risks assoc with aspiration:
- Asthma exacerbation from inhaled aerosolization of acid
- Frequent URI, sinus/ear infections
- Aspiration pneumonia
22
Q
GERD: Barrett’s epithelium (premalignant) or esophageal adenocarcinoma
A
- Cause: reflux of gastric fluids leads to esophagitis
- In chronic esophagitis, the body continuously heals inflamed tissue, eventually replacing normal esophageal epithelium w/ premalignant tissue or malignant adenocarcinoma
- Nursing actions:
- Determine cause of GERD w/ client
- Review lifestyle changes that can decrease gastric reflux
- Monitor nutritional status
23
Q
Hiatal Hernia
A
- AKA diaphragmatic hernia
- Protrusion of the stomach (in part or total) above the diaphragm into the thoracic cavity thru the hiatus/opening of the diaphragm
24
Q
2 types of hiatal hernia
A
- Sliding: more common
- Portion of the stomach and gastroesophageal junction move above the diaphragm
- Generally occurs w/ increases in intra-abdominal pressure or while the client is in supine
- Paraesophageal (rolling):
- part of the fundus of the stomach moves above the diaphragm although the gastroesophageal junction remains below the diaphragm
25
Hiatal Hernia: health promotion and dz prevention
* Avoid eating immediately prior to going to bed
* Avoid foods/drinks that dec LES pressure
* Exercise regularly
* Maintain healthy weight
* Elevate HOB at least 6 in
* Avoid straining or excessive vigorous exercise
* Avoid wearing clothing that is tight around abdomen
26
hiatal hernia: expected findings
* Presenting manifestations depend on type and are typically worse after a meal
* Sliding: heartburn, reflux, chest pain, dysphagia, belching
* Paraesophageal: fullness after eating, sense of breathlessness/suffocation, chest pain, worsening of symptoms when reclining
* Physical assessment:
* Pharyngitis
* inspiratory/expiratory wheezes
27
hiatal hernia: list diagnostic procedures
* barium swallow w/ fluoroscopy
* EGD
* CT scan of chest w/ contrast
28
hiatal hernia: barium swallow w/ fluoroscopy
* Allows visualization of esophagus
* Nursing Actions:
* Instruct client to use cathartics to evacuate the barium from the GI tract after procedure
* Failure to eliminate barium places client at risk for fecal impaction
29
hiatal hernia: EGD
* Allows visualization of esophagus and gastric lining
* Nursing Actions
* Verify gag response has returned prior to giving fluids/food following procedure
30
hiatal hernia: CT scan w/ contrast
* Allows visualization of the esophagus and stomach
* Nursing Actions:
* Assess for iodine allergies
* Encourage fluids following procedures to promote dye excretion and minimize risk of renal injury
* Monitor BUN/creatinine
31
hiatal hernia: 2 classes of meds
* PPIs
* antacids
32
hiatal hernia: PPIs
* pantoprazole, omeprazole, esomeprazole, rabeprazole, lansoprazole
* Reduce gastric acid by inhibiting the cellular pump of the gastric parietal cells necessary for gastric acid secretion
* Nursing Considerations:
* Monitor for electrolyte imbalances and hypoglycemia in clients who have DM
* Long term use has been related to the development of community acquired pneumonia and c. diff infections
* Client education:
* Long term use of PPIs places the client at risk for frxs, especially in older adults
33
hiatal hernia: antacids
* aluminum hydroxide, magnesium hydroxide, calcium carbonate, sodium bicarb
* Neutralize excess acid and increase LES pressure
* Nursing Considerations:
* Ensure there are no contraindications w/ other meds (levothyroxine)
* Evaluate kidney function in clients taking magnesium hydroxide
* Client Edu:
* Instruct client to take when acid secretion is the highest (1-3 hours after eating and at bedtime), and to separate other meds by at least 1 hour
34
what are the therapeutic procedures for hiatal hernia?
* Fundoplication: reinforcement of LES by wrapping portion of fundus of stomach around distal esophagus
* Laparoscopic Nissen fundoplication: minimally invasive w/ fewer complications
35
nursing considerations/client edu for hiatal hernia w/ the therapeutic procedures
* Nursing Considerations:
* Elevate HOB to promote lung expansion
* Instruct client to support incision during movement and coughing to minimize strain on suture lines
* Client Edu:
* Consume a soft diet for first week postop
* Avoid carbonated beverages
* Ambulate, but avoid heavy lifting
36
complications of the therapeutic procedures for hiatal hernia
* Temporary dysphagia
* Gas bloat syndrome (difficulty burping and distention)
* atelectasis/pneumonia
37
hiatal hernia: complications
* Volvulus: twisting of esophagus and stomach
* Obstruction (paraesophageal hernia): blockage of food in herniated portion of stomach
* Strangulation (paraesophageal hernia): compression of blood vessels to the herniated portion of the stomach
* Iron Deficiency Anemia (paraesophageal hernia): resulting from bleeding into gastric mucosa due to obstruction
38
esophageal varices
* Swollen, fragile blood vessels that are generally found in the submucosa of the lower esophagus, but varices can develop higher in the esophagus or extend ot the stomach
* Occurs as a result of portal HTN, usually due to cirrhosis of the liver
* When they hemorrhage, it is a medical emergency w/ high mortality
* Recurrence of esophageal bleeding is common
39
esophageal varices: health promotion and dz prevention
* Avoid alcohol
* Avoid heavy lifting
* Avoid straining w/ bowel movements
* Chew food completely, as poorly chewed foods can irritate the area
* Avoid salicylates and other meds that irritate the esophagus
40
esophageal varices: risk factors
* Portal HTN: elevated blood pressure in veins that carry blood from the intestines to the liver
* Alcoholic cirrhosis
* Viral hepatitis
* Older adults: frequently have depressed immune function, dec liver function, and cardiac disorders that make them vulnerable to bleeding
41
portal HTN
* Caused by impaired circulation of blood thru the liver--\>collateral circulation develops, creating varices in the upper stomach and esophagus
* Varices are fragile and can bleed easily
* Primary risk factor for development of esophageal varices
42
esophageal varices: expected findings
* May experience no manifestations until the varices bleed
* Hematemesis, melena, and general deterioration of physical and mental status
* Activities that precipitate bleeding→Valsalva maneuver, lifting heavy objects, coughing, sneezing, alcohol consumption
* Physical Assessment Findings w/ bleeding varices:
* Shock
* hypoTN
* Tachycardia
* Cool, clammy skin
43
esophageal varices: lab tests
* Liver fcn tests: indicate liver disorder
* H&H: can indicate anemia secondary to occult bleeding or overt bleeding
* Elevated serum ammonia level: indicates an inc nitrogen load from bleeding varices
44
esophageal varices: diagnostic procedures
* Endoscopy: therapeutic interventions can be performed during the endoscopy
* Nursing Actions:
* Administer preprocedure sedation
* After the procedure, monitor V/S and take measures to prevent aspiration
45
esophageal varices: nursing care
* If bleeding is suspected, establish IV access w/ a large bore needle, monitor V/S and HCT, type and cross match for possible transfusions, and monitor for overt and occult bleeding
46
esophageal varices: meds
* nonselective beta blockers
* vasoconstrictors
47
esophageal varices: nonselective beta blockers
* Propranolol: prescribed to decreased HR and consequently reduce hepatic venous pressure
* Used prophylactically (not for emergency hemorrhage)
48
esophageal varices: vasoconstrictors
* Octreotide: synthetic form of hormone somatostatin decreases the bleeding from the varices but does not affect BP
* Vasopressin causes constriction of esophageal and proximal gastric veins and reduces portal pressure
* Nursing Considerations:
* Vasopressin should not be given to clients who have coronary artery dz due to resultant coronary constriction
* Potent vasoconstriction can cause problems with peripheral and cerebral circulation
* If vasopressin is used with nitroglycerin IV in this client population, it can decrease or prevent the vasoconstriction of the coronary arteries
* Monitor for fluid retention and hyponatremia, as vasopressin has an antidiuretic effect
49
esophageal varices: list the therapeutic procedures used
* endoscopic variceal ligation (EVL)
* endoscopic sclerotherapy
* transjugular intrahepatic portal systemic shunt (TIPS)
* esophagogastric balloon tamponade
* surgical intervention
50
esophageal varices: endoscopic variceal ligation (EVL)
* Can be used w/ acute bleeding
* During endoscopy, the varices are rubber banded to cut off the circulation to the varices
* Necrosis of the tissue occurs w/ eventual sloughing off of the varix
* There is a significant decrease in rebleeding as well as decreased mortality postprocedure
* Complications:
* Superficial ulceration
* Dysphagia
* Temporary chest discomfort
* Esophageal strictures (rare)
* Nursing Actions:
* Administer preprocedure sedation
* After procedure, monitor V/S and prevent aspiration
51
esophageal varices: endoscopic sclerotherapy
* During endoscopy, a sclerosing agent is injected into the varices resulting in thrombosis of the varicosity
* Complications:
* Bleeding
* Perforation of the esophagus
* Aspiration pneumonia
* Esophageal stricture
* Nursing actions:
* Administer preprocedure sedation
* After procedure: monitor V/S and prevent aspiration
* Antacids, H2 receptor blockers, or PPIs may be administered after the procedure to protect the esophagus and prevent acid reflux which is often caused by sclerotherapy
52
esophageal varices: Transjugular intrahepatic portal-systemic shunt (TIPS)
* Used to tx an acute episode of bleeding when EVL and medications are not controlling the bleeding
* It rapidly lowers portal pressure
* Procedure is costly and is only used when other measures do not work
* While the client is under sedation or general anesthesia, a catheter is passed into the liver via the jugular vein in the neck
* A stent is then placed b/w the portal and hepatic veins bypassing the liver
* Portal HTN is subsequently relieved
* Complications:
* Bleeding
* Sepsis
* Heart failure
* Organ perforation
* Liver failure
* Nursing Actions:
* Monitor V/S
* Keep HOB elevated
53
esophageal varices: esophagogatric balloon tamponade
* Rarely used but can be used to temporarily control bleeding until another measure can be implemented
* Risks:
* Tube migration: which can lead to airway obstruction
* Aspiration of gastric contents into lungs
* Clients are often intubated to protect the airway
* Can cause necrosis of tissue if left in place for extended period of time
* Balloon should be in place no longer than 12 hours
* Nursing Actions:
* Check balloons for leak prior to insertion
* Monitor placement of the tube and observe for possible airway obstruction
* Monitor for aspiration into lungs and secretions or blood from esophagus
* Provide oral suction
* Maintain balloon pressure at prescribed pressure for prescribed time to dec risk of esophageal or gastric necrosis from ischemia
* Monitor the client who has dec mentation or confusion and who might pull on tube
54
esophageal varices: surgical intervention
* Last resort
* TIPS has replaced many surgical options
* High morbidity and mortality with surgery
* Bypass procedures establish a venous shunt that pypasses the liver and dec portal HTN
* Common shunts include:
* Splenorenal: splenic, left renal veins
* Mesocaval: mesenteric vein, vena cava
* Portacaval: portal vein, IVC
* Clients commonly have NG tube inserted to monitor for hemorrhage
* Nursing actions:
* Monitor for inc in liver dysfunction or encephalopathy
* Monitor NG tube secretions for bleeding
* Monitor PT, PTT, platelets, INR
55
esophageal varices: hypovolemic shock
* complication of esophageal varices
* due to hemorrhage from varices
* Nursing actions:
* Observe for manifestations of hemorrhage and shock (tachycardia, hypoTN)
* Monitor V/S, Hgb, Hct, and coagulation studies
* Replace losses and support therapeutic procedures to stop and control bleeding
