Gastroesophageal reflux disease AND NURSING MANAGEMENT

NURSING MANAGEMENT OF PATIENTS WITH Gastroesophageal reflux disease

1. Objectives OF THE SESSION Definition of GERD Risk factors and etiology Pathophysiology of GERD Clinical Manisfestations Diagnostic Evaluation Management Complications

2. Definition Backward movement of gastric contents in to esophagus due to relaxation of or incompetent LES,pyloric stenosis ,increased gastric volume or motility disorder Symptom or mucosal damage produced by the abnormal reflux of gastric content into the esophagus

3. Etiology GERD has a multifactorial etiology Alteration in the internal pressure of LES Displacement of the angle of GE junction

4. Risk factors Obesity /Pregnancy & tight clothing causes external pressure Chewing tobacco and cigarette smoking Diet :Consumption of fried, high fat and spicy food /use of caffeine and chocolate High level of estrogen and progestrone Drugs ( anticholinergics /Sedatives/Antihistamines ) can relax LES and irritate the esophagus.

5. Pathophysiology of GERD Due to etiological causes Malfunctioning of distal end of esophagus LES pressure lower then intragastric pressure c auses backflow of stomach content in to esophagus

6. esophageal irritation and inflammation Progresses gradually Sign & symptoms esophagitis prone to URTIs Esophageal stricture & Dysphagia Regurgitattion & Indigestion

7. Clinical Manifestations Frequent heartburn ( pyrosis ) Dyspepsia Regurgitation Dysphagia /Odynophagia GERD- related chest pain Discomfort ,hiccups,nausea,loss of weight,burping,bloating Belching Dry cough (sypmtoms of respiratory infection) Ear infections

8. Diagnostic evaluation Health history+PE Barium swallow Endoscopy PH monitoring Esophageal manometry

9. Esophago -gastro- duodenoscopy Upper endoscopy, also known as EGD , is a procedure in which a thin scope with a light and camera at its tip is used to look inside the upper digestive tract -- the esophagus, stomach, and first part of the small intestine, called the duodenum. Endoscopy (with biopsy if needed) In patients with alarm signs/symptoms Those who fail a medication trial Those who require long-term tx Absence of endoscopic features does not exclude a GERD diagnosis Allows for detection, stratification, and management of esophageal manisfestations or complications of GERD

10. A 24-hourpH study is often done in conjunction with the oesophageal manometry to monitor the levels and changes in acid content in the oesophagus over a 24-hour period, while the patient conducts his or her normal daily activities.  It is used to diagnose gastro-oesophageal reflux disease (GERD – digestive acid passing from the stomach, up into the oesophagus), to determine the effectiveness of medications that are given to prevent acid reflux and to determine if episodes of acidic reflux are causing chest pain. 24-hour pH monitoring

11. pH 24-hour pH monitoring-----Physiologic study Frequently performed for diagnosing GERD or reflux esophagitis. Determines the amount of gastroesophageal acid reflux . Accepted standard for establishing or excluding presence of GERD for those patients who do not have mucosal changes Trans-nasal catheter or a wireless, capsule shaped device

12. Ambulatory 24 hr. pH Monitoring Normal GERD

13. Esophageal Manometry Assess LES pressure, location and relaxation Assist placement of 24 hr. pH catheter Assess peristalsis Prior to antireflux surgery

14. Medication Antacids : magnesium hydroxide, calcium hydroxide, aluminum hydroxide( neutralises acid) Foaming agents : gaviscon (cover the stomach content with foam) H2 receptor blockers : cimetidine and ranitidine(block histamine receptors- pareital cell dec HCL-gastric acid secretion dece ) Proton pump inhibitors : omeprazole , pantoprazole , rabeprazole Prokinetics : metoclopramide (Prevents delayed gastric emptying by improving LES & Inc peristalsis)

15. Management Lifestyle modification Encourage patients to stop smoking/Alcohol & caffeine cessation Avoid meals before bedtime Elevate head of bed Maintain a healthy wt eat, small frequent meals to prevent gastric distention Wear loose fitting cloths Advice patients not to lie down for atleast 2-3 hrs after eating or bend over after eating

16. Surgical management Fundoplication : this procedure is also called Nissan fundoplication, the upper part is wrapped around the LES to strengthen the sphincters, prevent acid reflux and repair hiatal hernia Angelchik prosthesis : a c- shaped silicon prosthesis tied around the distal esophagus

17. Esophagogastrostomy : it is the resection of a portion of the esophagus and anastomosis of the remaining portion to the stomach Esophagectomy : it is removal of part or whole of the esophagus with use of a dacron graft to replace the resected part

18. Nursing management A ssessment : Monitor for heartburn ,regurgitation, dysphagia, and chest pain. Identify triggers: food, position, and stress. Pain assessment Monitor for pulmonary symptoms resulting from reflux of gastric content Assess for noctural regurgitation (coughing, choking, and mouthful of saliva) Obtain the nutritional history related to feeding habits of the patients

19. Nursing Diagnos i s Altered nutrition less than body requirement related t o inability to intake enough food because of reflux ,heartburn Acute pain related to food accumulation in esophagus . Risk for aspiration related to impaired swallowing Anxiety related to difficulty to ingest Knowledge deficit related to disease process

20. Nursing Intervention Medication Management: Administer antacids, histamine-2 (H2) blockers, or proton pump inhibitors (PPIs) as prescribed. Monitor for side effects and interactions.

21. Dietary modification Consult with clients concerning dietary habits and daily intake of nutrients Obtain baseline weight and daily weighing(wt loss if obese) Eat Small and frequents feeds Semisolid and warm foods can be better tolerated than cold Avoid tobacco & smoking Avoid foods that relax LES(Greasy/fatty foods/coffee/soft drink) Eat last meal 3hr before bed time Sit up for 1hr after meal watch acidic foods : Tomato ,citrus foods etc

22. Complications Barrett’s Esophagus (Esophagus metaplasia) esophageal stricture esophageal ulcer