GERD 1 P a g e Not a disease but a syndrome Chronic symptoms or mucosal damage secondary to reflux of gastric contents into the lower esophagus GERD P 971 975 Most common upper GI problem seen in adults Etiology Pathophysiology No single cause of GERD Reflux of acidic gastric contents into lower esophagus overwhelms defenses of esophagus Gastric HCl acid and pepsin secretions that reflux cause irritation and inflammation Incompetent LES Obesity pregnancy certain food such as caffeine and chocolate drugs such as anticholinergics and cigarette smoking Symptoms Heartburn pyrosis After a meal that occurs once a week with no evidence of mucosal damage o o May be relieved with milk antacids or water Dyspepsia discomfort centered in upper abdomen Hypersalivation water brash Noncardiac chest pain Persistent reflux occurring twice a week is considered GERD Respiratory symptoms wheezing coughing dyspnea Nocturnal discomfort that awakens patient Disturbed sleep patterns Hoarseness Sore throat Globus sensation Choking Regurgitation hot bitter or sour liquid in throat Complications Esophagitis Inflammation of the esophagus o o Can have esophageal ulcers o Repeated esophagitis causes scar tissue formation leading to dysphagia Barrett s esophagus Esophageal metaplasia o Flat epithelial cells in the distal esophagus change to columnar esophageal cells o precancerous lesion that increases patient s risk for esophageal carcinoma o 5 15 with chronic reflux have Barrett s o o Biopsy of esophagus confirm metaplasia o S S o Surveillance endoscopy recommended every 2 3 years None to mild Bleeding Perforation Respiratory complications Bronchospasm Laryngospasm o Cough o o o Cricopharyngeal spasm o o Chronic bronchitis o Pneumonia Asthma GERD 2 P a g e Usually diagnosed on basis of symptoms and patient s response to behavioral and drug therapies Performed to determine cause of GERD Endoscropy Biopsy and cytologic specimens Avoid factors that trigger symptoms Pay attention to diet and drugs that affect the LES acid secretions and gastric emptying Stop smoking Diagnostic Studies Lifestyle Modifications Weight reduction Nutritional Therapy Aggravates symptoms Fatty foods decreased LES pressure and rate of gastric emptying o Chocolate Peppermint o Tomatoes o o Coffee o o Milk especially at bedtime Tea Small frequent meals Avoid late evening meals and nocturnal snacking Take fluids between rather than with meals to reduce gastric distention Chew gum and oral lozenges to help symptoms of GERD by increased saliva production Drug Therapy Decreases volume and acidity of reflux Improves LES function Increases esophageal clearance Protects esophageal mucosa Proton Pump Inhibitors o More effective in healing esophagitis o Omeprazole PRILOSEC Pantopropazole PROTONIX Lansoprazole PREVACID o Decreases gastric HCl acid secretion by inhibiting protom pump mechanisms responsible for Hcl secretion o o Most common side effect headache Long term use of high doses increases risk of fractures hip wrist and spine Histamine Receptor Blockers H2 antagonists o Ranitidine ZANTAC famotidine PEPCID o Reduce symptoms and promote esophageal healing o o o Block the action of histamine on the H2 receptors to reduce acid secretion SE with aluminum constipation SE with magnesium diarrhea Sucralfate CARAFATE Anti ulcer drug o o Cytoprotective properties o SE constipation Cholinergic drugs o o o o Bethanechol URECHOLINE Increases LES pressure Improves esophageal emptying in the supine position Increases gastric emptying GERD 3 P a g e Reserved for patients with complications of reflux including esophagitis intolerance of medications stricture Barrett s metaplasia and persistence of severe symptoms Reduce reflux by enhancing integrity of LES o Also increases HCl secretion Prokinetic drugs o Metoclopramide REGLAN Promotes gastric emptying o o Reduces risk of gastric acid reflux o SE restlessness anxiety insomnia hallucinations Antacids o Quick by short lived relief of heartburn o Neutralizes HCl acid o Take 1 3 hours after meals and bedtime Surgical Therapy Endoscopic Therapy Endoscopic mucosal resection Photodynamic therapy Cryotherapy Radiofrequency ablation Nursing Management Refer patient to community resources for assistance in stopping smoking Avoid substances that decreased LES pressure and tone Encourage patient to follow the necessary regimen Elevate head approximately 30 degrees Place patient supine 2 3 hours following a meal Avoid food and activities that cause reflux PPI take medication before the first meal of the day Instruct patients to see HCP if symptoms persist due to Barrett s Instruct patient about possible medication side effects PPI headache o o H2 receptor blockers uncommon o o o Metoproclamide restlessness anxiety insomnia hallucinations o Antacids with aluminum constipation Antacids with magnesium diarrhea Sucralfate constipation Postoperative Care o Respiratory complications can occur due to high abdominal incision o Respiratory assessment RR rhythm pulse rate and rhythm pneumothorax dyspnea chest pain cyanosis o Deep breathing to fully expand the lungs o When peristalsis returns only fluids are given initially solids added gradually o Measure I O Teach patient to avoid gas forming foods to avoid abdominal d