GASTRO ESOPHAGEAL REFLUX DISEASE(GERD).pptx

GASTRO ESOPHAGEAL REFULUX DISEASE

1. GASTROESOPHAGEAL REFLEX DISEASE (GERD) DHIVYA.M M.SC NURSING 1 ST YEAR COLLEGE OF NURSING MTPG & RIHS

2. REVIEW OF ANATOMY AND PHYSIOLOGY OF ESOPHAGUS

3. The esophagus is a muscular channel that carries food from the pharynx to the stomach. It starts with the upper esophageal sphincter, formed in part by the cricopharyngeus muscle, and ends with the lower esophageal sphincter, surrounded by the crural diaphragm. When food enters the mouth, it mixes with saliva. The actions of salivary enzymes convert food into a mass called a food bolus. Once the food bolus reaches the pharynx, swallowing starts, and relaxation of the upper esophageal sphincter ensues to allow passage of the food bolus into the esophagus . The bolus then travels down the esophageal body aided by peristaltic contractions of the esophageal muscles. When it finally reaches the distal end of the esophageal body, it triggers relaxation of the lower esophageal sphincter, which in turn permits entry of the food bolus into the stomach.

4. TERMINOLOGIES: Heartburn: a burning sensation in the chest or throat, caused by stomach acid backing up into the esophagus. It is most common symptom of GERD. Regurgitation: the sensation of stomach contents, including acid and partially digested food, rising into the throat or mouth. Acid reflux: the backward flow of stomach acid into the esophagus, which can cause symptoms such as heartburn and regurgitation. Esophagitis: inflammation of the esophagus, often caused by irritation from stomach acid. It can lead to symptoms such as difficulty swallowing, chest pain and bleeding.

5. Lower esophageal sphincter: A muscular valve at the lower end of the esophagus that opens to allow food and liquid to enter the stomach and closes to prevent stomach contents from refluxing back into the esophagus. Proton pump inhibitors: medications that reduce the production of stomach acid and are commonly used to treat GERD symptoms. Antacids: over the counter medications that neutralize stomach acid to provide temporary relief from heartburn and acid reflux symptoms.

6. DEFINITION Gastroesophageal reflux disease (GERD) is a chronic symptom of mucosal damage caused by reflux of stomach acid into the lower esophagus. GERD is not a disease but a syndrome Gastroesophageal reflux disease (GERD) is a common disorder that develops when gastric contents flow upward into the esophagus. GERD refers to the reflux of gastric contents into the esophagus. As this happens, the patient experiences pyrosis, a substernal burning sensation often radiating to the neck, commonly called heartburn.

7. INCIDENCE The prevalence of GERD in India ranges from 7.6% to 30%, being < 10% in most population studies, and higher in cohort studies. The dietary factors associated with GERD include use of spices and non-vegetarian food. Epidemiology GERD occurs in 15–20% of all adults. For many of these people, daily symptoms are common. Persons at risk for developing GERD are: hiatal hernia, pregnancy, scleroderma, obesity, certain medications (e.g., anticholinergics, beta-blockers, bronchodilators), consumption of alcohol, and cigarette smoking.

8. ETIOLOGY: Two common problems result in GERD: an incompetent LES, a motility disorder of the esophagus as previously described; and pyloric stenosis. In addition, the aging process correlates with an increased incidence of GERD Abnormalities of Lower esophageal spinchter : The LES is tonically contracted under normal circumstances, relaxing only occurs during swallowing. Some patients with GERD disease have reduced LES tone, permitting reflux when intro-abdominal pressure rises. In others, basal sphincter tone is normal but reflux occurs in response to frequent episodes of inappropriate sphincter relaxation. Weak lower esophageal sphincter (LES): the LES is a muscular ring at the junction of the esophagus and stomach. When it becomes weak or relaxes abnormally, stomach acid can flow back into the esophagus, causing irritation and inflammation. Reduced tone of LES and inappropriate relaxation of LES are the main cause of GERD

9. Hiatal hernia: This occurs when a portion of stomach protrudes into the diaphragm, weakening the LES and increasing the risk of acid reflux. Hiatus hernia cause reflux because pressure gradient between abdominal and thoracic cavities, which normally pinches the hiatus, is lost. In addition, oblique angle between the cardia and esophagus disappears. Delayed esophageal clearance: Defective esophageal peristaltic activity is commonly found in patients who have esophagitis. It is a primary abnormality, since it persist after esophagitis has been healed by acid suppressing drug therapy. Poor esophageal clearance leads to increased acid exposure time.

10. Defective gastric emptying: the etiology for delayed and defective gastric emptying is idiopathic. Increased intra-abdominal pressure: pregnancy and obesity are established predisposing causes. Weight loss may improve symptoms. Dietary factors: certain foods and beverages can trigger or exacerbate GERD symptoms such as spicy foods, acidic foods, caffeine, alcohol and fatty foods and chocolates. Obesity: excess weight can increase abdominal pressure, leading to the displacement of the stomach and promoting reflux.

11. Pregnancy: Hormonal changes and increased pressure on the abdomen during pregnancy can contribute to GERD. Smoking Certain medications: certain antibiotics, NSAIDS, calcium channel blockers. Genetic predisposition Other medical conditions: scleroderma, diabetes and delayed gastric emptying Lifestyle factors: factors like lying down or bending over after eating, eating large meals, and eating too close to bedtime can exacerbate GERD symptoms.

12. PATHOPHYSIOLOGY: During the swallowing process, the LES is normally closed. The backflow of gastric juices up into the esophagus is consequently prevented because of the difference in the pressure between the lower esophagus and the stomach. In GERD, the LES relaxes or is incompetent and the gastric contents are allowed to move upward during times of increased pressure. Examples of pressure changes are when the stomach volume is increased, as after a meal or when the patient bends down. The gastric contents are acidic and are made of pepsin and bile. These substances are irritating and over time the mucosa of the esophagus is affected by GERD, leading to esophagitis. Ulcerations may develop, which can result in bleeding, scarring, and strictures.

13. CLINICAL MANIFESTATION: The clinical manifestations of GERD can vary in severity and may include: Heartburn and regurgitation often provoked by bending, straining, etc pyrosis (burning sensation in the esophagus) is present 30 to 60 minutes after meals and in reclining position sensation of globus (sensation of something in throat) dyspepsia (indigestion) Regurgitation Dysphagia odynophagia (pain on swallowing)

14. hypersalivation Atypical Chest pain may be severe and mimic angina Hoarseness or sore throat due too acid laryngitis Chronic cough Wheezing or asthma Laryngitis Recurrent chest infections. Dental erosions Nausea

15. Vomiting Pharyngitis Some patients are woken at night by choking and refluxed fluid irritates larynx. Waterbrash: it is salivation due to reflux salivary gland stimulation as acid enters the gullet, is often present. Abdominal bloating will be present which is called as gas bloat syndrome. Recurrent aspiration pneumonia

16. Barrett’s esophagus: Barrett’s esophagus is a pre-malignant condition in which normal squamous lining of LES is replaced by columnar mucosa , columnar lines esophagus (CLO) that may contain areas of intestinal metaplasia which develops in cancer . Barrett’s esophagus generally develops because of chronic reflux esophagitis (GERD). The patient may describe heartburn or a burning taste in the back of the throat. At times patients may describe a sensation of saliva filling the mouth. This symptom is brash water.

17. DIAGNOSTIC EVALUATION: History collection Physical examination Endoscopy: a procedure in which a flexible tube with a camera (endoscope) is inserted through the mouth into the esophagus, stomach and upper small intestine. This allows direct visualization of the esophageal lining, assessment of esophageal inflammation, and detection of complications such as barrett’s esophagus or esophageal strictures’ Esophageal pH monitoring: this test measures the frequency and duration of acid reflux episodes by placing a small catheter through the nose into the esophagus which senses acid exposure over 24 hours

18. Esophageal manometry: A test to assess esophageal motility and the function of the LES by measuring pressures in the esophagus during swallowing Barium swallow X-ray: ingestion of barium solution, which coats the esophagus and stomach. This will help identify structural abnormalities such as hiatal hernia or strictures. Ambulatory pH monitoring: 12-36 hours test which measures frequency of acid exposure. Intraluminal impedance monitoring: Intraluminal impedance monitoring, which measures changes in the resistance to electrical current across adjacent electrodes. Bilirubin monitoring ( Bilitec ): It is used to measure bile reflux patterns. Exposure to bile can cause mucosal damage.

19. MANAGEMENT: MEDICAL MANAGEMENT: Pharmacological: Antacids: neutralize stomach acid to provide short term relief. ( Eg : gelusil ) H2 receptor antagonists ( H2Ras): reduce stomach acid production ( Eg : ranitidine, famotidine) Proton pump inhibitor: these are Acid suppressors, often prescribed for moderate to severe GERD ( eg : omeprazole, esomeprazole) Prokinetics: it helps to strengthen the lower esophageal sphincter and promote stomach emptying ( eg : metoclopramide, motilium ) Foaming agents: It helps to coat the stomach and prevent reflux ( eg : Gaviscon, etc.)

20. SURGICAL MANAGEMENT: The surgical management of Gastroesophageal Reflux Disease was done only when medical management is not effective. Surgical management involves a Nissen Fundoplication which is wrapping of a portion of the gastric fundus around the sphincter area of the esophagus)

21. This procedure can be performed either by laproscopy or by open method. Endoscopic ablation therapy ( Eg : photodynamic therapy PTD) , esophagectomy are the surgical interventions for Barrett’s esophagus.

22. Endoscopic treatment for GERD: Endoscopic radio frequency ablation therapy ( Eg : photodynamic therapy PTD) , esophagectomy are the surgical interventions for Barrett’s esophagus or only for those with dysplasia or intramucosal cancer Stretta procedure is radiofrequency energy delivery system used to provide thermal burn to gastroesophageal junction. Endocinch procedure uses an endoscopic sewing device to create pleats with a series of sutures passed through adjoining folds at proximal fundus. Enteryx , an endoscopically implanted device, prevents reflux of gastric acid into the throat. It is a permanent treatment to GERD.

23. NURSING MANAGEMENT: Educate the patient with GERD to: Eat small meals and avoid eating two to three hours before sleeping. Rinse the throat with water after each meal, as this neutralizes the esophagus and cleanses the esophagus from the gastric juices. Sit in a semifowler’s position after eating. Avoid irritating food substances (caffeine, alcohol, or acidic foods, fatty foods). Cease smoking, as it increases gastric acidity and interferes with healing of the esophagus. Patient is instructed to eat low fat diet, to avoid carbonated beverages. Educate to avoid tight fitting clothes.

24. NURSING DIAGNOSIS:   Risk for aspiration related to frequent reflux episodes Imbalanced nutrition less than body requirement related to dysphagia or discomfort associated with eating. Acute pain related to esophageal irritation. Anxiety related to chronic discomfort or fear of exacerbating symptoms Ineffective coping related to chronic illness management. Deficient knowledge regarding GERD.  

25. COMPLICATIONS: The complications of Gastroesophageal Reflux Disease includes : Esophagitis : inflammation or irritation of the esophagus due to repeated exposure to stomach acid, leading to pain, difficulty swallowing and potentially bleeding or ulcers. Esophageal stricture: Narrowing of the esophagus due to scarring from chronic inflammation, causing difficulty swallowing and potentially leading to food getting stuck ( dysphagia) Barrett’s esophagus: chronic inflammation of the esophagus that can lead to changes in the cells lining the lower esophagus, increasing the risk of esophageal cancer.

26. Respiratory complications: Aspiration of stomach contents into the lungs can lead to aspiration pneumonia, chronic cough, or exacerbation of asthma symptoms. Dental problems: chronic exposure to acid can erode tooth enamel, leading to dental decay, sensitivity, or other oral health issues. Reflux induced laryngitis: Irritation and inflammation of the larynx caused by stomach acid leading to hoarseness, sore throat and difficulty speaking. Erosive esophagitis: Severe inflammation of the esophagus lining, potentially leading to ulcers and bleeding

27. PROGNOSIS: The prognosis of GERD is generally favorable with appropriate management. Most individuals with GERD can achieve symptom control and prevent complications with a combination of lifestyle modification, medications, and sometimes surgical interventions. However, the prognosis can vary depending on several factors: Severity of symptoms Response to treatment Presence of complications Adherence to Treatment Underlying Health conditions. Overall, with appropriate treatment and management, the prognosis for most individuals with GERD is good, they can lead a normal, symptom free life. However, long term monitoring and follow up with healthcare providers are important to ensure optimal outcomes and prevent complications.

28. CONCLUSION: GERD can significantly impact on individual’s quality of life and potentially lead to complications if left untreated, effective management strategies are available. Early diagnosis and proactive management are crucial to prevent complications. GERD can achieve symptom control and maintain good quality of life. Regular monitoring and follow up with healthcare providers are essential to ensure optimal outcomes and prevent disease progression.