MedSurg- GERD and Hiatal Hernia

What is a symptom of mucosal damage? 

A reflux of gastric acid, pepsin, trypsin and bile in the lower esophagus 

What is the irritation and inflammation called?

Esophagitis

What is a major risk?

Obesity

What is the cause of GERD?

A weak or incompetent lower esophageal sphincter

Some food contributors to GERD?

Alcohol, smoking, chocolate, fatty food, caffeine, peppermint, spearmint

What medications are contributors to GERD? 

Anticholinergics, beta blockers, calcium channel blockers, diazepam (valium), morphine sulfate, nitrates, theophylline and progesterone

Some of the clinical manifestations of GERD?

Heartburn, dyspepsia, regurgitation, respiratory symptoms and a hoarseness or lump in the throat, choking

When is heartburn or pyrosis concerning?

There are persistent to mild symptoms more than twice a week and moderate to severe symptoms once a week

How is dyspepsia described?

A pain in the upper abdomen

Possible respiratory symptoms?

Wheezing, coughing and dyspnea

When do some CM need further evaluation?

• severe heartburn 

• heartburn > 2x a week 

• heartburn with dysphagia

• occurs at night 

• awakens person from sleep 

• older person with recent onset of heartburn

Why is it important to look further into older individuals with these concerns?

The heartburn could potentially be a cardiac issue that would need checking out

Some complications that can be experienced?

Esophagitis, ulcers, Barrett esophagus and fibrosis, scarring

What group of people mostly experience Barrett esophagus?

Those who may be centrally obese and white men over the age of the 60

What is an extreme risk for those with Barrett esophagus?

Increased risk of cancer

What is experienced with fibrosis and scarring?

Strictures and dysphagia

What is strictures?

The narrowing of the esophagus

What diagnostic studies can be done for GERD? 

Endoscopy, biopsy, manometric studies and esophageal pH monitoring 

What does an endoscopy look for?

LES competence and any inflammation, scarring and strictures

What is observed for in a biopsy?

Dysplasia

How are manometric studies applied?

Looks for pressures and any motility

How high do we want to elevate the HOB?

By 30 degrees

• can also use pillows to 4 to 6 inch blocks 

How long after a meal should you avoid laying down?

2 to 3 hours

Why should you avoid bending over?

Can cause more acid reflux and lead to vomiting

Should you wear tight fitting clothes around your waist?

No

How many hours before bed should you stop eating?

3 hours

What is the biggest thing we want to stop? 

Smoking 

Why is reducing stress levels important?

Increases your cortisol levels and causes more acid to be made

Why is it important to increase your physical activity level? 

This lowers the obesity risk and increase GI motility 

• also eat a low fat diet 

What are some ways that distention of the stomach can be avoided? 

By eating small frequent meals which is about 4-6 meals a day

What types of beverages should be avoided?

Alcohol, caffeine and acidic beverages

What drugs decrease volume and acidity of reflux?

H2 receptor blockers and proton pump inhibitors

What is a goal of H2 receptor blockers?

Inhibits the parietal cells for making hydrochloric acid

How do the H2 receptors work?

• onset of action: 1 hr

• lasts 12 hrs 

• can be combined with an acid 

How should proton pump inhibitors be administered?

• Once daily dosing

• Take before the first meal of the day 

What are some of the long term effects of taking a proton pump inhibitor?

Decreased bone density, kidney disease, vitamin b12 and magnesium deficiency  

What are adjunct medications?

Antacids

What is the goal of antacids? 

To neutralize acid 

Patient teaching with antacids?

• 1-3 hours after meals and bedtime 

• Effects last 3 to 4 hours 

• Relieve heartburn for 20 to 30 minutes

• Take before bed and when you really need it 

How does prokinetic drug therapy work?

Increases the LES pressure, increases gastric emptying and increases gastric motility

• meds: Reglan and Metoclompramide (increases the gut) 

What foods should you stay away from so that LES pressures aren’t decreased?

Chocolate, peppermint, fatty foods, coffee and tea

Caffeine, alcohol, acids foods and liquid are all what?

Irritants

What can occur when you eat too late, have a nighttime snack or drink milk at bedtime?

There will be an increase in gastric acid secretion

To prevent stomach distention?

• have small frequent meals 

• Drink fluids between meals 

How can we increase our saliva production?

Chewing gum

Different ways that Laparoscopic Surgical Therapy can work? 

• Enhances LES integrity 

• Wrap the fundus of stomach around the esophagus 

• LINx Reflux Management System 

Goal of enhancing the LES integrity?

protects against reflux

What is fundoplication and what should be done post-operatively?

The fundus of the stomach is wrapped around the esophagus to stop stomach acid from flowing back up

• Dysphagia for the first month post operatively 

How does the LINX Reflux Management System work?

• There are magnets in titanium rods that are connected by titanium wires

• Helps to keep the LES closed (nausea, swallowing problems and pain when swallowing food) 

What is a big no no with the LINX system?

MRI’s (due to magnets)

What does an endoscopic therapy do?

Thickens the LES

• Endoscopic mucosal resection 

• Radiofrequency ablation 

What is a hiatal hernia? 

portion of the stomach that protrudes up through the opening in the diaphragm 

A type 1 hernia?

There is prolonged exposure

• can slide

• GEJ through diaphragm when supine

• Acid Reflux (Barrett’s esophagitis) 

• Strictures 

• Dysphagia

• Erosions (cameron lesions) 

A type 2 hernia? 

Will create a pocket within the esophagus

• can roll 

• Fundus of stomach through diaphragm (pocket alongside the esophagus) 

• Fullness after eating, breathless after eating, chest pain 

• Volvulus and obstruction 

What is ascites? 

A 3rd spacing of fluid in abdomen

Pathophysiology of hiatal hernias? 

• weakening of muscles in the diaphragm

• Aging (due to muscles not being as strong anymore) 

• Increased intra-abdominal pressure (ex: obesity, pregnancy, ascites, tumors, physical exertion, heavy lifting

Clinical Manifestation for hiatal hernia?

This is comparable to GERD symptoms

• Acid is in the stomach where it should not be 

Complications of hernias? 

• Esophagitis, bleeding from erosion, stenosis, ulceration of herniated portion of stomach 

• Strangulation of hernia (loss of blood supply to that area of the stomach) 

• Regurgitation with tracheal aspiration (aspirational pneumonia)

Esophagitis is? 

inflammation of the esophagus 

Ulceration of herniated portion of stomach is? 

Portion of stomach in the esophagus 

Some ways to reduce intra-abdominal pressure? 

• no constricting clothing

• No lifting/Straining

Antacids do what?

Neutralize acid

H2 receptor blockers?

• Reduce acid production 

• Famotidine (Pepcid) 

Proton Pump Inhibitors

• Block acid production 

• Omeprazole (Prilosec OTC) 

What is done with a laparoscopic procedure?

Nissen/Toupet Fundoplication

• Top of the stomach is wrapped around the esophagus 

• Higher recurrence rate 

What can be done during an open procedure?

• Gastropexy 

• Herniotomy  

• Herniorrhaphy 

Gastropexy is?

Attaching the stomach below the diaphragm

Herniotomy is?

Removing the herniated sac

Herniorrhaphy is?

Repairing and/or closing the hiatal defect

What is the main muscle of respiration?

Diaphragm

Things to watch post-operatively?

• Clots 

• Things related to the chest in regard to venous return 

• Watch age- as it can be riskier for some individuals 

Nursing interventions to consider?

• Sleep with HOB elevated 

• Lose weight (decrease abdominal pressure)

• Avoid tobacco and alcohol 

• Reduce Stress 

Things that should be assessed?

• Heartburn 

• Regurgitation 

• Dysphagia

• Belching

• Breathlessness

Why is there concern with older adults? 

• At an increased risk

• Increased abdominal pressure due to weakened diaphragm, obesity and kyphosis 

• Take meds that decrease LES pressure; nitrates, CCB, antidepressants 

• Not as active to move around anymore