Week 8: Esophageal, GERD, Hiatal Hernia, Obesity, N+V

GERD definition

damage due to reflex of stomach acid into the lower esophagus because of an incompetent lower esophageal sphincter (LES).

factors that affect LES pressure

overeating, drugs, obesity, smoking, hiatal hernia, mucosal damage

GERD manifestations

pyrosis (heartburn), dyspepsia (indigestion), regurgitation, wheezing/coughing/dyspnea, nighttime disturbances, hoarseness, sore throat, lump in through, choking, inc saliva

GERD complications

esophagitis - ulcerations, dysphagia. barett’s esophagus. cough, broncho/laryngo/circopharyngeal spasms. aspiration → asthma, chronic bronchitis, pneumonia. dental erosion.

GERD dx studies

upper GI endoscopy, barium swallow/esophagram, esophageal motility (flowscopy)

GERD collab care

assess gag reflex after upper endoscopy, avoid irritants - alc, caffeine, smoking. upright after 2-3 meals, don’t eat less than 3 hr before bed, avoid tight clothing/waist pressure raise HOB, lose weight, avoid irritating foods - milk before bed (gas), chocolate, fatty foods, peppermint, caffeine. Encourage small meals + fluids between meals. surgery - fundication (wrap stomach around LES)

PPIs

lansoPRAZOLE, omerPRAZOLE, pantoPRAZOLE - decreases acid secretion and irritation. SE headache, n+v, diarrhea.

histamine 2 receptor blockers

cimeTIDINE, famoTIDINE - decreases HCl acid secretion. SE headache, n+v, diarrhea

prokinetics

metoclopramide - promotes gastric emptying and decreases reflux. SE tremor, dyskinesia (EPS), anxiety, hallucinations

cholinergics

bethanechol - increases LES, improves esophageal emptying, increases gastric emptying. SE lightheadedness, flushing, diarrhea

hiatal hernia definition

portion of stomach sticks out from the diaphragm. sliding - most common, occurs w/ intraabdominal pressure, stomach “slides up”. paraesophageal/rolling - less common, more harmful, piece of stomach protrudes up.

hiatal hernia pathophys

weakened diaphragm muscle + esophagogastric opening, increased intraabdominal pressure. predispositions - obesity, pregnancy, continuous heavy lifting, ascites, tumor.

hiatal hernia manifestations

similar to GERD - some are asymptomatic. can have pyrosis, dyspepsia, regurgitation, resp symptoms, chest pain.

hiatal hernia complications

GERD, esophagitis, ulcers, hemorrhage, stenosis, strangulation, aspiration

hiatal hernia dx studies

barium swallow, endoscopy.

hiatal hernia collab care

gag reflex, avoid food before bed + triggering gas and reflux, and avoid intraabdominal pressure.

hiatal hernia gerontologic considerations

older - weaker diaphragm and LES pressure. triggered by nitrates, calcium channel blockers, nsaids, k+. first sign might be severe - esophageal bleeding or aspiration.

esophageal cancer pathophys

usually result of cell damage (increases risk) can metastasize to the liver and lungs, usually diagnosed late.

esophageal cancer risk factors

barrett’s esophagus, smoking, alcohol, obesity

esophageal cancer manifestation

dysphagia, substernal/epigastric/back pain, weight loss, regurgitation, neoplasm, may cause obstruction later

esophageal cancer dx

endoscope w/ biopsy, endoscopic US

esophageal cancer tx

surgery, laser, endoscopic mucosal resection, ablation (heat), radiation, chemo, targeted therapy

esophageal cancer post op care

chest tube, IV, ng tube, pain mgmt. encourage coughing, deep breaths, incentive spirometer - pneumonia prevention. VTE prophylaxis, follow up radiation/chemo

obesity risk factors

genetic + environmental factors

health risks for obese patients

cvd, stroke, diabetes, GERD + liver problems, sleep apnea, hypoventilation, osteoarthritis, cancer, metabolic syndrome, stigma

obesity teaching

any weight loss is beneficial, weigh self weekly

obesity collab care

reduce caloric intake, limit fat, cholesterol, salt, sugar. water, exercise, behavior modification therapy, support groups. antidepressants (bupropion) decrease appetite, GLP-1 agonist (liraglutide, semaglutide)

bariatric surgery

restrictive, malabsorptive, or combination. criteria - BMI >40 or BMI >35 w/ complications

bariatric surgery pre op

reinforced trapeze on bed, chlorhexidine + hygiene, turn, teach pneumonia prevention, may be on cpap, prep w/ appropriate size equipment

bariatric surgery post op

splint, HOB 45 degrees, wound care - dehiscence + evisceration, anastomosis (connected ends leak), drain care, ngt care - intermittent suction until bowel sounds return, fluids, I+O, pain mgmt, VTE prophylaxis. begin w/ 15 mL water po and then slowly increase. drink 30 min before or after meals (not with!)

bariatric surgery complications

absorption factor (cobalamin) deficiency → iron deficiency, GI tract leaks, ulcer, hernia, dumping syndrome

dumping syndrome prevention

decrease sugary foods, no liquids with meals, eat slowly, six small meals, high protein low carbs + fats, avoid fiber and rough. dehiscence, evisceration

nausea and vomiting assessment

identify food that was eaten. color, smell, texture, timing. bright red - active bleeding. coffee-grounds - gastric bleeding.

n+v clinical problems

fluid imbalance, electrolyte imbalance, poor nutrition, impaired GI function.

n+v collab care

NPO, IV fluids, electrolytes. persistent → NG tube, ensure security to prevent irritation. high carb low fat bland diet. take liquids between meals to reduce distention.

n+v gerontologic considerations

higher risk for electrolyte imbalance, more susceptible to CNS SE of antiemetics - lower doses.