Esophageal/swallowing disorders, GERD, PUD, IBD

Achalasia

Smooth muscles of lower esophageal sphincter fails to relax, impairing passage of food into the stomach

Cause of achalasia

Disruption of input from enteric pleural plexus and vagus nerve

Manifestations of achalasia

• Dysphagia

• Regurgitation of food

• Chest pain

• Weight loss

How is achalasia treated?

• Balloon dilation therapy

• Botox injection

• Surgery

How is achalasia diagnosed

Endoscopy

esophageal diverticulum

Herniation of esophageal wall (pouch/pocket that forms in the wall of the esophagus)

esophageal diverticulum manifestations

• Dysphagia

• Gurgling

• Foul breath

how is esophageal diverticulum diagnosed

• Esophagram

• Endoscopy

esophageal diverticulum management

• smaller meals

• avoid certain foods

What is Mallory-Weiss syndrome?

Longitudinal tears in the esophageal lining caused by forceful / repeated vomiting

Mallory-Weiss syndrome risk factors

Frequent vomiting- alcohol misuse, eating disorders

Mallory-Weiss syndrome manifestations

• Abdominal/epigastric pain

• Hematemesis

• Melena

How is Mallory-Weiss syndrome diagnosed

Upper endoscopy

What is a hiatal hernia?

Part of the stomach protrudes through the diaphragm into the chest cavity

manifestations of a hiatal hernia

Similar to GERD- heartburn/reflux, chest pain, dysphagia

how is a hiatal hernia managed

• Smaller meals

• Avoid lying down after eating

• Weight management

• Surgery

dysphagia

difficulty swallowing

odynophagia

pain with swallowing

GERD (Gastroesophageal reflux disease)

Gastric contents back-flow into the esophagus due to weak lower esophageal sphincter

manifestations of GERD

• Heartburn- 30-60 min after meals

• Belching

• Epigastric/chest discomfort

• Nighttime cough

• Laryngitis

complications of GERD

• Barrett esophagus

• Esophageal strictures

• Esophagitis

How is GERD diagnosed

• Assessment of symptoms

• Esophageal pH monitoring

• Endoscopy

• Barium swallow test

GERD lifestyle changes

• Avoid personal trigger foods

• Eat smaller, more frequent meals

• Remain upright after meals

• Stop smoking

Medications used for GERD

• Antacids

• H2 receptor antagonists

• PPIs

Antacids

Neutralizes stomach acid in the GI tract

Examples of antacids

• Sodium bicarbonate

• Calcium carbonate (tums)

• Magnesium hydroxide

• Aluminum hydroxide

Antacid adverse effects

• Magnesium: diarrhea

• Aluminum/calcium: constipation

Antacid indications

• PUD

• GERD

• Stress ulcers

H2 receptor antagonists mechanism of action

Suppresses secretion of gastric acid by blocking H2 receptors in parietal cells lining the stomach

examples of H2 receptor antagonists

• Famotidine (Pepcid)

• Cimetidine (Tagamet)

Proton pump inhibitors mechanism of action

reduces stomach acid by targeting final step of acid production in the stomach

proton pump inhibitors suffix

“-prazole”

H2 blockers suffix

“-tidine”

How long can the acid-suppressing effect of PPIs last

24-72 hours

examples of PPIs

• Omeprazole (Prilosec)

• Pantoprazole (Protonix)

When should most delayed-release PPIs be taken

30-60 minute before a meal

potential risks of prolonged PPI use

increased risk of bone fractures (increase Ca and Vit D)

What is the difference between antacids, H2 blockers, and PPIs

• Antacids neutralize existing acid

• H2 blockers reduce acid secretion through histamine receptor blockade

• PPIs inhibit the final step of acid secretion

peptic ulcer disease

Open sores in the lining of the stomach or duodenum caused by damage to the protective mucosal barrier

major causes/risk factors of PUD

• H. Pylori infection

• Long-term NSAID use

• Excess acid

• Smoking

gastric ulcer

ulcer located in the stomach

How does gastric ulcer pain typically relate to meals?

often worsens during / shortly after eating

duodenal ulcer

ulcer located in the duodenum, the first part of the small intestine

How does duodenal ulcer pain typically relate to meals?

Food may temporarily relieve pain because food absorbs stomach acid. Remember “duodenal = do eat”

manifestations of PUD

• Burning, gnawing, or cramping epigastric pain

• Nausea/vomiting

• Possible GI bleeding

major complications of PUD

• Hemorrhage

• Perforation

• Gastric outlet obstruction.

How do PPI’s help PUD

reduces acid secretion and allows the ulcer to heal

What do bismuth salts do in PUD treatment?

protects the mucosal lining and have activity against H. pylori as part of combination therapy

How is H. pylori-associated PUD treated?

combination of acid suppression and antibiotics, sometimes with bismuth

What is sucralfate (Carafate)

mucosal-protective drug that adheres to ulcerated tissue and forms a barrier against acid, pepsin, and bile salts

sucralfate nursing considerations

• Take on empty stomach

• Separate other meds by 2 hours

Where does Crohn’s disease occur

Anywhere along GI tract (mouth-anus) but most commonly involving terminal ileum

inflammation pattern in Crohn’s disease

Patchy, “skip lesions” with normal, healthy areas in between affected segments

How deeply does Crohn’s disease affect the bowel wall?

Entire thickness, all layers

What are granulomas in Crohn’s disease

Clusters of inflammatory cells that may be seen in affected tissue- not present in every patient

manifestations of Crohn’s disease

• abdominal pain

• diarrhea

• weight loss

• fatigue

• fever

Complications of Crohn’s disease

• Strictures / blockage

• Fistulas

• Abscesses

• Malnutrition / malabsorption

Where does ulcerative colitis occur

Rectum and colon (large intestine)

Main treatment for Crohn’s disease

Corticosteroids

Inflammation pattern in ulcerative colitis

Continuous inflammation, affecting the mucosa lining

Manifestations of ulcerative colitis

• Bloody diarrhea

• Urgency to defecate

• Rectal bleeding

• Lower abdominal cramps

• Weight loss

• Fatigue

complications of ulcerative colitis

• toxic megacolon

• bowel perforation

• severe bleeding

• increased colorectal cancer risk

How do Crohn’s disease and ulcerative colitis differ

Crohn’s can affect any GI region, has skip lesions and affects all layers of GI wall; UC affects the colon/rectum, has continuous inflammation and primarily mucosal involvement

What tests help diagnose IBD

• Blood tests

• Stool tests

• Colonoscopy

• Sigmoidoscopy

ulcerative colitis treatment

• Corticosteroids

• Immunodulators

• 5-ASAs

What are 5-ASAs?

5-aminosalicylates or aminosalicylates, group of anti-inflammatory medications as first-line treatment for inflammatory bowel disease (IBD)

When are antibiotics used in IBD?

For certain complications like abscesses and fistulas

PUD treatment

• PPIs

• H2 blockers

• Antibiotics for H. pylori

• Bismuth salts