PART 1 DISTURBANCES IN INGESTION

GASTROESOPHAGEAL REFLUX DISEASE (GERD)

common disorder marked by backflow of gastric or duodenal contents into the esophagus that causes troublesome symptoms and/or mucosal injury to the esophagus.

• The "Pushers" (Increased Abdominal Pressure):

  • Obesity: Extra weight pushes down on the stomach.
    

  • Pregnancy: The growing baby pushes up on the stomach.
    

  • Hiatal Hernia: A structural defect where the top of the stomach bulges up through the diaphragm.

• The "Weakens" (Systemic Issues):
  

  • Aged Person: Muscles (including sphincters) get weaker with age.
    

  • COPD: Chronic coughing increases chest pressure; breathing struggles affect the diaphragm.
    

  • H. Pylori Infection: Bacteria that damages the stomach lining.

predisposing factors of GERD

The Theme: "Bad Habits"

• The "Relaxers" (Things that drug the valve open):

  • Smoking: Chemicals relax the sphincter.

  • Alcohol & Caffeine: loosen the valve and increase acid.

  • Medications (Aspirin): Directly irritate the stomach lining.

• The "Overloaders" (Things that overfill the tank):

  • Eating Large Meals: Fills the stomach to the brim, making overflow easy.

  • Eating Late at Night: Lying down immediately takes away gravity's help.

  • Fatty/Fried Foods: These take a long time to digest, so food sits in the stomach longer (delayed emptying).

Precipitating Factors (The "Triggers") of GERD

1. Epigastric burning, worse after eating

2. Heartburn

3. Burping (Eructation) or Flatulence

4. Sour taste in mouth, often worse in the morning

5. Nausea

6. Bloating

7. Cough due to reflux high in the esophagus

8. Sore throat

9. Hoarseness or change in voice

HALLMARK SIGNS AND SYMPTOMS OF GERD

1. The "Surveillance Camera" (24-Hour pH Monitoring)

This is the most accurate test.

• What it does: A tiny probe is placed in your esophagus for a full day.

• What it looks for: It measures pH (acidity). Since the esophagus should be neutral, any "elevations" in acidity mean the acid is breaking in.

• Analogy: Like a security camera recording exactly when and how often the burglar (acid) breaks in over 24 hours.

2. The "Glowing Road" (Barium Swallow / Upper GI Study)

• What it does: You drink a chalky liquid called Barium. This liquid shows up bright white on X-rays.

• What it looks for: As you swallow, the doctor takes X-ray videos. If they see the white liquid moving back up from the stomach, that is visual proof of reflux.

Analogy: Like pouring neon paint into a river to see which way the current flows.
➢ If the result is fully white, then there is no gastric mucosa problem but when you see black, then the mucosa is irritated.

3. The "Inside Look" (Endoscopy / EGD)

• What it does: A flexible tube with a camera (Endoscope) is put down your throat.

• What it looks for: The doctor looks directly at the tissue for irritation (redness/burns) or cellular changes.

• Key Concept (Barrett's Esophagus): This test is crucial for spotting Barrett's Esophagus—a condition where the cells change shape because they are sick of being burned by acid.

• Analogy: Like sending a tiny GoPro down the tunnel to inspect the damage on the walls.

4. The "Strength Test" (Esophageal Manometry)

• What it does: A tube measures pressure readings in your esophagus.

• What it looks for: It specifically measures the tone (strength) of the Lower Esophageal Sphincter (LES).

• Analogy: Like a grip-strength test for the "door" (sphincter). It checks if the door is closing tight enough or if it's too weak to hold the acid back.

COMMON LABORATORY OR DIAGNOSTIC PROCEDURES OF GERD

DO NOT let the patient undergo Barium swallow

test if there is an active bleeding for it isn’t

effective at all.

can you do barium swallow when there is active bleeding?

Side effect of this diagnostic procedure is

constipation.

(NURSING CONSIDERATION:

increase fluid intake).

side effect of barium swallow and nursing consideration

➢ Done inside the operating room

➢ Pre-op nursing responsibilities: informed

consent, NPO for 3 hours, left side lying position

➢ Barrett’s esophagus – cancer, named after the

one who discovered the disease.

➢ Post-op nursing responsibilities: universal fall

precautions

ENDOSCOPY or EGD (esophagogastroduodenoscopy) pre op and post op nursing responsibilities

✓ Low-fat diet (fat contains glycerol thus containing

alcohol)

✓ Avoid alcohol, milk (contains lactate acid), caffeinated,

and carbonated drinks

✓ Avoid foods containing peppermint or spearmint (mint

increases HCl that further aggravates the patient’s

condition)

✓ Avoid eating or drinking 2H prior bedtime

✓ Eat six small meals rather than three large ones to

reduce intra-abdominal pressure

✓ Stop smoking (it has nicotine, which contains asphalt, that sticks to the cilla/villi, destroying the gastro musosa)

✓ Maintain normal weight

✓ Avoid tight fitting clothes

✓ Elevate HOB at least 30° esp. after eating

NON-PHARMACOLOGIC TREATMENT OF GERD

EDUCATE PATIENT REGARDING :

• Administer ANTACIDS to neutralize acid; these

medications act quickly (Maalox, Mylanta, Tums,

Gaviscon)

• Administer HISTAMINE TYPE 2 (H2) BLOCKERS to

decrease the production of acid (ranitidine, famotidine,

nizatidine, cimetidine)

• Administer PROTON PUMP INHIBITORS (PPIS) to reduce the production of acid (omeprazole, esomeprazole, pantoprazole, rabeprazole, lansoprazole)

• Administer PROMOTILITY AGENTS (metoclopramide, domperidone)

PHARMACOLOGIC TREATMENT IN GERD

Antacids: "The Fire Extinguisher"
(Maalox, Mylanta, Tums, Gaviscon)

These are your first responders. They don't stop the fire from starting, but they spray water on it to cool it down immediately.

• Action: Neutralize the acid that is already there.

• Speed: They act quickly (instant relief).

• Examples:

Administer HISTAMINE TYPE 2 (H2) BLOCKERS to decrease the production of acid (ranitidine, famotidine, nizatidine, cimetidine)

These drugs tell the stomach's workers (histamine receptors) to take a break, so less acid is made.

• Action: Decrease the production of acid.

• Examples:

Administer PROTON PUMP INHIBITORS (PPIS) to reduce the production of acid (omeprazole, esomeprazole, pantoprazole, rabeprazole, lansoprazole)

These are the heavy hitters. They go to the source—the "pump" that squirts acid into the stomach—and shut it down completely.

• Action: Reduce (block) the production of acid (more powerful than H2 blockers).

• Metoclopramide

• Domperidone

If the stomach is a clogged highway, these drugs wave the cars through to clear the jam.

• Action: They force the stomach to empty faster (improving peristalsis) so acid doesn't sit around and splash back up.

• Examples:

given to the elderly patient

➢ Side effects: confusion and dizziness

➢ Nursing consideration: fall precaution

H2 blockers side effects and considerations

PPI is the drug of choice

➢ Given 7-14 days

➢ Dosage: 20 mg BID, 40 mg OD

➢ 2 preparations: IV, PO

➢ Timing: 5:30 AM & 5:30 PM (BID) ; 5:30 AM or

upon waking up before breakfast or bedtime (OD)

➢ Esomeprazole: Drug of choice but it is expensive

is the drug of choice

➢ Given: days

➢ Dosage: BID, OD

➢ 2 preparations:

➢ Timing:

➢ Drug of choice but it is expensive

itopride

Promotility Agents

(has lesser side effects than domperidone and doesn’t affect the cardiac rate)

domperidone

Promotility Agents

(indicated for delayed gastric emptying and indigestion but can affect cardiac rate)

ondansetron

Promotility Agents

(given in CS pregnant mothers)

metoclopramide

Promotility Agents

(pre-op meds in general anesthesia)

HIATAL HERNIA

opening in the diaphragm through which the

esophagus passes become enlarged, and part of

the upper stomach moves up into the lower

portion of the thorax.

• Congenital: You were born with a defect (Diaphragmatic Hernia).

• Aging: Muscles weaken as you get older (>50 y/o).

• Genetics (Male): Men and certain families are more prone to it.

• Esophageal Ring/Diverticula: Structural flaws in the tube itself.

• Disease (GERD): Chronic acid reflux can scar and shorten the esophagus, pulling the stomach up.

PREDISPOSING FACTORS HIATAL HERNIA

• Smoking: Weakens the muscle and causes chronic coughing (which increases pressure).

• Pregnancy: The baby takes up space and pushes the stomach up.

• Obesity: Extra weight puts constant pressure on the abdomen.

• Trauma/Surgery: A blow to the stomach or surgical damage weakens the area.

• Strain: Any activity that spikes pressure (Coughing, heavy lifting, straining on the toilet).

PRECIPITATING FACTORS OF HIATAL HERNIA

acid burn
1. Heartburn

2. Dysphagia

3. Eructation

4. Chest Pain

Sliding Hernia signs and symptoms

1. Chest pain

2. Shortness of breath after eating

3. Feeling of fullness after eating

signs and symptoms rolling hernia

1. The Smoke Detector (24-Hour pH Monitoring)

• What it does: Tracks acid levels over a full day.

• The Note: "Shows elevations."

• Translation: It detects when the "fire" (acid) is where it shouldn't be. This is the best way to prove that acid is actually leaking.

2. The Blueprint Check (Barium Swallow / Upper GI)

This is the most important visual test for a Hernia.

• What it does: You drink a chalky liquid that lights up on X-rays.

• The Note: "Shows how big the hiatal hernia is and if there is twisting."

• Translation: It shows the Shape and Structure.

  • Size: Is it a small slip or a huge bulge?

  • Twisting: In a Rolling Hernia, the stomach can twist (volvulus), which is dangerous. This test sees that.

3. The Camera Inspection (Endoscopy / EGD)

• What it does: A camera goes down to look at the walls.

• The Note: "Shows irritation from cellular changes... monitor Barrett’s esophagus."

• Translation: It checks for Damage. It looks for burns, redness, or "Barrett's" (precancerous changes) caused by the chronic acid exposure.

4. The Door Hinge Test (Esophageal Manometry)

• What it does: Measures pressure.

• The Note: "Measure lower esophageal sphincter tone."

• Translation: It tests the Strength of the valve. Is the door loose? Is it closing tight enough?

5. The Drainage Test (Gastric Emptying Studies)

• What it does: You eat radioactive food (safe amounts) and they watch how fast it leaves.

• The Note: "Examine how fast food leaves the stomach... important in patients who have nausea and vomiting."

• Translation: It tests the Speed.

  • If the "drain" is clogged (Delayed Gastric Emptying), food sits there and rots, causing nausea/vomiting.

  • Why it matters: If a patient is vomiting, you need to know if it's because of the Hernia or because the stomach is just lazy (Gastroparesis).

COMMON LABORATORY OR DIAGNOSTIC

PROCEDURES OF HIATAL HERNIA

EDUCATE PATIENT REGARDING:

• Low-fat diet

• Avoid alcohol, milk, caffeinated, and carbonated drinks

• Avoid foods containing peppermint or spearmint

• Avoid eating or drinking 2H prior bedtime

• Eat six small meals rather than three large ones to reduce

intra-abdominal pressure

• Stop smoking

• Maintain normal weight

• Avoid tight fitting clothes – creates pressure

• Elevate HOB at least 30° esp. after eating

NON-PHARMACOLOGIC TREATMENT OF HIATAL HERNIA

• Administer ANTACIDS

-to neutralize acid; these medications act quickly

(Maalox, Mylanta, Tums, Gaviscon)

- side effect: constipation

• Administer HISTAMINE TYPE 2 (H2) BLOCKERS

-to decrease the production of acid (ranitidine,

famotidine, nizatidine, cimetidine)

• Administer PROTON PUMP INHIBITORS (PPIS)

-to reduce the production of acid (omeprazole,

esomeprazole, pantoprazole, rabeprazole,

lansoprazole)

PHARMACOLOGIC TREATMENT OF HIATAL HERNIA

Increased risk of bone fractures (Osteoporosis).

Long-term acid suppression can interfere with calcium absorption, weakening bones.

side effects of PPI in long term use

ACHALASIA

• From Greek word “chálasis” meaning "loosening,

relaxation”

• absent or ineffective peristalsis of the distal esophagus accompanied by failure of the esophageal sphincter to relax in response to swallowing.

Myenteric plexus

is a plexus of nerves found in

between longitudinal and circular muscle layers in

the small intestine that controls motility along the

gastrointestinal tract.

➢ Plexus of nerves means that it involves

sympathetic and parasympathetic function.

➢ The brains send signals through these nerves to open or close the sphincter. But because

inflammation happens, the brain cannot control it

anymore. Eventually it will become dead which

makes the sphincter remain close

Step 1: Myenteric Inflammation (The Fire)

• What happens: Something (Virus? Autoimmune?) sets the "wiring" on fire.

Location: The Myenteric Plexus (Auerbach's plexus). This is the network of nerves sandwiched between the muscle layers that controls movement.

• Analogy: The fuse box in the basement catches fire.

Step 2: Loss of Nerve Cell Function (The Blackout)

• What happens: The fire burns out the nerves. Specifically, the Inhibitory Nerves (the ones that tell muscles to "Relax") die off.

• The Result: The signal to "Open the Door" is lost forever.

• Analogy: The wire connecting the "Unlock" button to the front door is melted. You can press the button all you want, but the signal never gets there.

Step 3: Inappropriate Contraction (The Jammed Door)

• What happens: Because the "Relax" signal is dead, the muscle defaults to its natural state: Squeezed Shut.

• The Result: The smooth muscle in the distal (bottom) esophagus stays contracted (high pressure), and the body of the esophagus twitches randomly instead of pushing smoothly.

• Analogy: The electronic lock on the door fails in the "Locked" position. It is now permanently stuck shut.

PATHOPHYSIOLOGY OF ACHALASIA

Bird’s beak can be found when patient undergo

Barium swallow x-ray because of the narrowing of the sphincter. Therefore Barium swallow test is the

confirmatory test.

what is the confirmatory test in achalasia and why?

A. Dysphagia (The "Stuck" Feeling)

• The Sign: Trouble swallowing both solids AND liquids.

• Why: In other diseases (like cancer), usually only solids get stuck. In Achalasia, the muscle is paralyzed, so it can't even push water through the tight valve.

• The Outcome: If you can't eat, you get Decreased Caloric Intake → Weight Loss.
  

B. Regurgitation (The "Rebound")

• The Sign: Undigested food comes back up.

• Why: The food has nowhere to go but up. It never touched the stomach acid, so it often tastes just like the food you chewed (undigested).
  

C. "Fake" Heartburn

• The Sign: Epigastric or retrosternal burning sensation.

• Why: This isn't always acid reflux. It's often the food rotting (fermenting) in the esophagus or the acid irritating the lining because it's trapped.
  

D. Sense of Fullness

• The Sign: Feeling stuffed or heavy in the chest.

• Why: The intake of food/water piles up and puts pressure on the esophagus, expanding it like a water balloon

signs and symptoms of achalasia

• Aspiration: Food/liquid enters the lungs.

• The Result:

  • Pneumonia / Pneumonitis: Infection or inflammation in the lungs.

  • Chronic Cough: Trying to clear the lungs.

  • Asphyxiation: Choking.

complications of achalasia

A. The Visuals (What it Looks Like)

• Barium Swallow / X-ray (Esophagram): You drink a chalky liquid. On the X-ray, the esophagus looks like a "Bird’s Beak." The top is wide and dilated (because food is stuck there), and the bottom is very narrow where the muscle won't open.

• CT Scan of the Chest: Used to see the overall structure and ensure the dilation isn't caused by something outside the esophagus pushing on it.

B. The Direct Look (The Camera)

• Endoscopy: A camera goes down the throat.

• Why? To rule out (r/o) Barrett’s Esophagus or cancer. Sometimes a tumor can "mimic" achalasia by blocking the path, so the doctor needs to see the tissue directly.

C. The "Gold Standard" (The Pressure Test)

• Esophageal Manometry: This is the most important one to memorize for exams!

• What it does: A tube measures pressure.

• What it finds: It confirms the diagnosis by showing:

  1. High pressure at the bottom (the valve won't relax).

  2. No peristalsis (no rhythmic pushing waves) in the rest of the pipe.

COMMON LABORATORY OR DIAGNOSTIC PROCEDURES OF ACHALASIA

• The Allergy Check (Seafood/Iodine):

  • Why: Iodine is found in many types of seafood. If a patient is allergic to shellfish/seafood, they are at a very high risk of an allergic reaction to the contrast dye.

• The Kidney Check (Creatinine):

  • Why: The kidneys are responsible for filtering the iodine out of the body through urine.

  • The Problem: If Creatinine levels are abnormal (too high), it means the kidneys are already struggling. Adding heavy iodine can "overload" them, leading to severe complications.

IV Contrast nursing considerations

remove jewelries

MRI nursing considerations

EDUCATE PATIENT REGARDING :

✓ Low-fat diet

✓ Avoid alcohol, milk, caffeinated, and carbonated drinks

✓ Avoid foods containing peppermint or spearmint

✓ Avoid eating or drinking 2H prior bedtime

✓ Eat six small meals rather than three large ones to

✓ reduce intra-abdominal pressure

✓ Eat slowly and to drink fluids with meals (you can use teaspoon instead of spoon to swallow food easily)

✓ Stop smoking

✓ Maintain normal weight

✓ Avoid tight fitting clothes

✓ Elevate HOB at least 30° esp. after eating

NON-PHARMACOLOGIC TREATMENT OF ACHALASIA

Nitrates (Example: Isosorbide)

The Price You Pay (Side Effects): Because they relax all smooth muscles (including your blood vessels), your blood pressure drops.

• Hypotension (Low BP)

• Headache (Blood vessels in the head dilate)

• Drowsiness

ACHALASIA
How they work: They stop the muscle from squeezing (inhibition) and force it to relax so the esophagus can empty.
Side effects:

CALCIUM CHANNEL BLOCKERS (nifedipine,

verapamil)

• ⏰ Pro-Nursing Tip: These must be taken 30–60 minutes before a meal so the "power is cut" before the food arrives.

• The Price You Pay:

  • Hypotension (Low BP)

  • Tolerance (Over time, the body might stop responding to them)

ACHALASIA

How they work: Muscles need Calcium to "power" a contraction. These drugs block the calcium. No Calcium = No Contraction. This forces the LES to stay relaxed.
Timing:
Side effects:

5-PHOSPHODIESTERASE INHIBITORS

(sildenafil)

hypertension & angina

ACHALASIA

How they work: They trigger the release of Nitric Oxide, which is the body's natural "relax" signal for the LES. This reduces the pressure in the sphincter.

Side effects:

used also for erectile dysfunction

BOTULINUM TOXIN

PNEUMATIC DILATION OF THE HYPERTONIC LES

ENDOSCOPIC THERAPIES OF ACHALASIA

PNEUMATIC DILATION OF THE HYPERTONIC LES

ENDOSCOPIC THERAPIES OF ACHALASIA

• How it works: A high-pressure balloon is placed inside the LES and inflated.

• The Science: The goal isn't just to stretch the muscle, but to fracture (tear) the muscle fibers. By "breaking" the muscle, it can no longer stay tight.

BOTULINUM TOXIN

ENDOSCOPIC THERAPIES OF ACHALASIA

It blocks Acetylcholine (the chemical signal that tells muscles to contract). Without that signal, the muscle can't squeeze shut, allowing food to drop through via gravity (passive emptying).

botulism (food poisoning)

➢ Can cause paralysis and worse, death

Botulinum toxin can cause

1.Occult blood stool exam

2.Blood test to check for hemoglobin (low

hemoglobin count indicates bleeding)

2 tests to diagnose if there is an internal bleeding in

the GI tract

LAPAROSCOPIC HELLER MYOTOMY PLUS

ANTIREFLUX FUNDOPLICATION

ACHALASIA SURGICAL TREATMENTS

• The Procedure : The surgeon makes a long cut in the muscular layer of the Lower Esophageal Sphincter (LES) to "snap" the tight fibers that won't relax.

  • Fundoplication (The "Safety Wrap"): Because cutting the muscle makes the LES stay open, stomach acid will now splash up. To prevent this, the surgeon wraps the top of the stomach around the esophagus to create a new, one-way pressure valve.

• Post-Op Risks: Even with the wrap, some patients develop Chronic Reflux. Over time, this acid exposure can lead to Barrett's Esophagus (precancerous changes in the lining).

ESOPHAGOGASTRECTOMY WITH GASTRIC OR

COLONIC INTERPOSITION

ACHALASIA SURGICAL TREATMENTS

• The Solution (The "Replacement"): The surgeon removes the non-functioning esophagus.

• Interposition: To "bridge the gap" between the throat and the stomach, they pull up a piece of the colon or the stomach to act as the new food pipe.

• The Risks: This is a major, invasive operation. The biggest concern is Conduit Necrosis (if the blood supply to the new colon/stomach pipe fails) or severe leaks at the surgical connection points.