GERD

Question 1

GERD

Answer 1

A disorder of the LES; bile, pancreatic enzymes, and stomach acid refluxes into the esophagus

Question 2

Clinical manifestations

Answer 2

ESOPHAGEAL symptoms:

1. Pyrosis
2. Regurgitation
3. Dysphagia
4. Odynophagia (painful swallowing)
5. N/

EXTRA-ESOPHAGEAL symptoms (reflux affects structures other than the esophagus and stomach):

1. Chronic cough
2. Chest pain
3. Laryngitis
4. Asthma/SOB/pneumonia/bronchitis
5. Pharyngitis
6. Sinusitis
7. Sleep apnea
8. Erosion of dental enamel
9. Otitis media

Question 3

Complications of GERD

Answer 3

Complications:
1. Reflux esophagitis – erosion of esophagus resulting in ulcers near stomach-esophageal junction

2. Esophageal strictures – narrowing of esophagus caused from reflux-induced inflammation and scarring
3. Barret’s esophagus – intestinal metaplasia (precancerous lesion of the esophagus)
4. Esophageal adenocarcinoma

Question 4

Risk factors:

Answer 4

GERD risk factors:
1. Genetics (single most important cause)

2. Hiatal hernia (80%) – increases GERD due to mechanical and motility factors
3. Obesity – high BMI is related to increased risk of GERD
4. Zollinger’s (rare) – increased gastric acid secretion due to gastrin production
5. Hypercalcemia – increased gastrin production (and acidity)
6. Scleroderma and systemic sclerosis – causes esophageal dysfunction
7. Meds. – NSAIDs (can lead to pyrosis)

Question 5

Diagnosis

Answer 5

1. Esophageal pH monitoring – Wireless capsule inserted into esophagus (gold standard)
2. Esophageal manometry or esophageal motility study (EMS) – assess motor function of UES and LES; Catheter is inserted into nose to stomach, and is slowly withdrawn, detecting pressure changes (no sedation, ~45 min.)
3. EGD and barium swallow

Question 6

Medical management

Answer 6

1. Lifestyle modification – exercise, diet
2. Medication – PPI & H2 receptor blockers = Reduce gastric acid secretion; Sucralfate = heal and prevent further damage of esophagus, but also prevents absorption of other drugs
3. Surgery – Nissen fundoplication (laparoscopically tighten the LES) and Linx (magnetized beads assist the LES)

Question 7

Nursing management

Answer 7

1. Assess symptoms – especially related to timing of pain
2. Role in pt education
3. Consult dietician
4. Encourage daily journal – what they ate?/length of meal time?/pain when eating?/alleviating factors?/OTC meds?

Question 8

Pt education

Answer 8

Promote:
1. Lifestyle modifications to lose weight

2. Raise HOB 6 inches
3. Avoid foods that worsen symptoms – coffee, chocolate, ETOH, peppermint, fatty foods
4. Monitor for other symptoms (extraesophageal) – teeth enamel, recurrent otitis media
5. Smoking cessation
6. Several meals throughout day
7. Avoid lying down after eating
8. When to contact PCP – symptoms persists, cannot relieve symptoms
9. Contact PCP immediately – trouble swallowing, food “stuck” when swallowing, lose weight, chest pain, choking, hematemesis, bloody stool

Question 9

Care coordination

Answer 9

1. Dietary – note food journal, devise diet with several small meals
2. Pharmacy (monitor drug interaction) – Long-term PPI use (dementia due to decreased Ca2+ intake), Sulfacrate (prevents drug absorption), and devise drug plan