Gastric Esophageal Reflux

Question 1

What is GERD?

Answer 1

Common problem

Chronic manifestation of mucosal damage

Question 2

What causes GERD

Answer 2

Caused by reflux of gastric contents into lower esophagus

Question 3

Is GERD a disease?

Answer 3

No it is a syndrome

Question 4

GERD results when?

Answer 4

Defenses of lower esophagus are overwhelmed by reflux of gastric contents into esophagus

Reflux of HCl acid and pepsin secretions cause irritation and inflammation
Intestinal proteolytic enzymes and bile salts add to irritation

Question 5

What are Predisposing factors of GERD

Answer 5

Hiatal Hernia

Decreased esophageal clearance

Decraesed Gastric Emptying

Question 6

Hiatal hernia?

Answer 6

Incompetent lower esophageal sphincter (LES): Biggest culprate

Causing:

Antireflux barrier

Question 7

What is decreasesed esophageal clearance?

Answer 7

incompetent LES (lower esophageal sphincter) takes longer for food to leave esophagus

Question 8

What does incompetent LES cause?

Answer 8

Primary factor in GERD

Results in ↓ pressure in distal portion of esophagus

Gastric contents move from stomach to esophagus

Can be due to certain foods (caffeine, chocolate, peppermint) and drugs (anticholinergics): decrease pressure in LES increasing GERD

Question 9

Other risk factors?

Answer 9

Obesity is a risk factor

Pregnant women are at increased risk

Cigarette and cigar smoking can contribute to GERD

Hiatal hernia is a common cause of GERD

Question 10

Symptoms of GERD?

Answer 10

Heartburn (pyrosis)

Dyspesia

Regurgitation

Question 11

Symptoms of Heartburn?

Answer 11

Most common clinical manifestation

Burning, tight sensation felt beneath the lower sternum and spreading upward to throat or jaw

Felt intermittently

Question 12

Symptoms of Dyspepsia

Answer 12

Pain or discomfort centered in upper abdomen

Question 13

Symptoms of regurgitation?

Answer 13

Described as hot, bitter, or sour liquid coming into throat or mouth

Hypersalivation may also be reported

Question 14

Most individuals have mild symptoms such as?

Answer 14

Heartburn after a meal:
to consider as GERD it will happen at least twice a week
No evidence of mucosal damage

Question 15

When does Heartburn occur?

Answer 15

Following ingestion of food or drugs that ↓ LES pressure

Directly irritates esophageal mucosa

Question 16

Individual may also report respiratory symptoms such as?

Answer 16

Wheezing

Coughing

Dyspnea

Nocturnal coughing with loss of sleep

Can mimic asthma due to inflammation of the trachea causing voice hoarseness and sore throat

Question 17

Otolaryngologic symptoms include

Answer 17

Hoarseness

Sore throat

Lump in throat

Choking

Question 18

Symptoms of GERD-related chest pain

Answer 18

Described as burning, squeezing, or radiating to back, neck, jaw, or arms

Can mimic angina

More common in older adults with GERD

Relieved with antacids

Question 19

Complications of GERD

Answer 19

òEsophagitis

Barrett’s esophagus (esophageal metaplasia): When healing process occurs: follow up with biopsy can be cancerous

Respiratory

Potential for asthma, bronchitis, and pneumonia

Dental erosion

From acid reflux into mouth

Especially posterior teeth

Question 20

Diagnostic Studies

Answer 20

History and physical examination
Barium swallow
Upper GI endoscopy
Biopsy and cytologic specimens
Esophageal manometric (motility) studies: measures pressure of LES

Radionuclide tests

Detect reflux of gastric contents

Demonstrate rate of esophageal clearance

Monitoring pH

Laboratory or 24-hour ambulatory

Determine esophageal pH by using specially designed probes

Question 21

Nutritional Therapy

Answer 21

Decrease high-fat foods

Take fluids between rather than with meals

Avoid milk products at night: Temporarily helps but has a rebound effect due to calcium increasing acid content

Avoid late-night snacking or meals

Avoid chocolate, peppermint, caffeine, tomato products, orange juice

Weight reduction therapy

Chewing gum and oral lozenges can increase saliva production and help patients with mild symptoms

Question 22

What kind of drug therapy is given?

Answer 22

Proton pump inhibitors (PPIs)

Question 23

What are common PPI’s?

Answer 23

omeprazole (Prilosec)

esomeprazole (Nexium)

Question 24

How do PPI’s help?

Answer 24

Promote esophageal healing in 80% to 90% of patients

Decrease incidence of esophageal strictures

Decrease the rate of gastric acid secretion

Question 25

What is the most common side effect of PPI's and why?

Answer 25

***Headache***: ## Footnote ***It interferes with the absorption of Magnesium and Calcium. Magnesium is crucial for nerve transmission***

Question 26

What other drug alerts are there with PPI's?

Answer 26

Long-term use or high doses of PPIs may increase the risk of fractures of hip, wrist, and spine: Due to interfering with the absorption of calcium

Question 27

PPI's are asssociated with an increased incidence of what and why?

Answer 27

C. difficile infection in hospitalized patients: Due to altering gastric contents: usually seen in those with a hx

Question 28

What other types of drugs are used in GERD?

Answer 28

***Histamine-2 receptor (H2R) blockers*** Cholinergic Prokinetic drugs Antacids Drugs with cytoprotective properties

Question 29

***Histamine-2 receptor (H2R) blockers*** ***Name*** ***How they work*** ***side effects***

Answer 29

***Decrease secretion of HCl acid*** Reduce symptoms and promote esophageal healing in 50% of patients Example: ***cimetidine (Tagamet), famotidine (Pepcid): Prophylactic in hospitals to prevent stress ulceres, rantidine*** Side effects uncommon

Question 30

Drugs with cytoprotective properties and teaching needed

Answer 30

***sucralfate (Carafate):*** ***Give 30 minutes before you eat because it works better in low Ph***

Question 31

Cholinergic Drugs Name How they work

Answer 31

Increase LES pressure Improve esophageal emptying Increase gastric emptying Example: bethanechol (Urecholine):

Question 32

Prokinetic drugs Name How they work

Answer 32

Promote gastric emptying Reduce risk of gastric acid reflux Example: metoclopramide (Reglan)

Question 33

Antacids Name How they work Pt teaching

Answer 33

Quick but short-lived relief Neutralize HCl acid ***Taken 1–3 hours after meals/at bedtime*** Example: Maalox, Mylanta

Question 34

What kind of ***surgical therapy*** can be done?

Answer 34

***laparoscopic Nissen fundoplication***

Question 35

When is surgical therapy necessary?

Answer 35

Failure of conservative therapy Medication intolerance Barrett’s metaplasia Esophageal stricture and stenosis Chronic esophagitis

Question 36

Patient Teaching

Answer 36

***Elevation of head of bed 30 degrees*** ***Not lying down for 2–3 hours after eating*** ***Avoidance of late-night eating*** ***Avoidance of factors that cause reflux*** Stress reduction techniques Weight reduction, if appropriate ***Small, frequent meals***

Question 37

Postoperative care Focus

Answer 37

Prevention of respiratory complications Maintenance of fluid/electrolyte balance Prevention of infection

Question 38

Postoperative care Respiratory assessment

Answer 38

Respiratory rate/rhythm Pulse rate/rhythm Signs of pneumothorax

Question 39

What are Signs of pneumothorax

Answer 39

Dyspnea Chest pain Cyanosis

Question 40

Post Operative Care General

Answer 40

Deep breathing techniques Accurate I/O Observing for fluid/electrolyte imbalance Pain medication Medications to prevent nausea/vomiting

Question 41

Postoperative care diet

Answer 41

When peristalsis returns, ***only fluids given initially*** Solids added gradually Normal diet gradually resumed Patient must avoid gas-forming foods and must chew foods thoroughly

Question 42

Postoperative care after teaching for after D/C

Answer 42

First month after surgery, patient may report mild dysphagia; should resolve after edema subsides Patient should report persistent symptoms such as heartburn and regurgitation