GI oral and esophagus disorders

Decay

Erosive process driven by bacteria and carbohydrates

Acid

Bacteria + Fermentable Carbs =

Dental plaque, acid exposure, acid strength, tooth susceptibility

Factors influencing dental damage

Decay in enamel → dentin → pulp

Stages of tooth decay

Fluoride varnish/gel applications

Professional primary prevention and control

Water fluoridation and fluoride toothpaste

Community and home care for dental plaque and caries

Smoking cessation and limiting alcohol

Lifestyle modification for dental plaque and caries

Mechanical cleansing

Brushing and flossing

Nursing responsibilities of dental plaque and caries

• soft-bristled brushes > foam sticks or sponges

• Gauze wipe w/antiseptic rinse

• Water-soluble gel

Cariogenic alternatives

Dietary modifications for dental plaque and caries

Pit and fissure sealants

Coating is applied to seal deep grooves of primary and permanent molars that are prone to decay, last 36 to 48 months.

Cheilosis (Angular Stomatitis)

Erythema and fissuring (bleed or develop yellowish crust), maceration, crusting and bleeding

Vitamin B2 (Riboflavin), B12, Iron, or Folate

Nutritional deficiencies as causes of cheilosis

Ill-fitting dentures

Mechanical cause of cheilosis

Candida albicans (fungal) or Staph aureus (bacterial)

Infection fungal and bacterial causes of cheilosis

Intake of Vitamin B rich foods - leafy greens, lean meats, dairy

Dentist - for ill-fitting dentures

Nursing Considerations of cheilosis (angular stomatitis)

Actinic Cheilitis

• irritation of lips associated with scaling, crusting, fissure

• White hyperkeratosis

• Considered premalignant squamous cell skin cancer

White hyperkeratosis

Overgrowth of horny layer of epidermis

Exposure to sun and chronic inflammatory lesion (leads to squamous cell cancer)

Causes of actinic cheilitis

• Sun block lips

• Periodic checkup

Nursing considerations of actinic cheilitis

Aphthous Stomatitis (canker sore)

• shallow ulcer with a white or yellow center and typically a well-defined red border

• Inner side of the lip, cheek, tongue

• Burning or tingling sensation and slight swelling and painful

• Lasts 7-10 days (minor) and heals without a scar

• HIV infection - immune-mediated inflammatory disorder

• Emotional or mental stress, fatigue, hormonal factors, minor trauma (biting), allergies, acidic foods/juices, and dietary deficiencies

• May recur

Causes of Aphthous stomatitis

• comfort measures (saline rinses) and soft/bland diet

• Antibiotics or corticosteroids

• OTC benzocaine

Nursing considerations of aphthous stomatitis

Herpes Simplex virus-1 (cold sore or fever blister)

• Symptoms may be delayed up to 20 days after exposure

• Singular or clustered, irregular, painful vesicles throughout the oral cavity and lips that may rupture

Opportunistic infection, immunocompromised patients, recur w/menstruation, fever, or sun exposure

Causes of herpes simplex virus-1 (cold sore or fever blister)

• acyclovir ointment

• Analgesic agents

• Avoid irritating foods

Nursing considerations of herpes simplex virus-1 (cold sore or fever blister)

Candidiasis (moniliasis/thrush)

• cheesy white plaque that looks like milk curds

• Erythematous and often bleeding base (when rubbed off)

• Candida albicans (fungus)

• Diabetes, antibiotic therapy, immunosuppression

Causes of candidiasis

Antifungal medications - nystatin or clotrimazole

Swish vigorously - 1 min and then swallow

Oral agents - fluconazole

Nursing considerations of candidiasis

Vincent’s Angina

• trench mouth or acute necrotizing ulcerative gingivitis

• Sudden onset, punched-out ulcers, grayish pseudomembrane

• Halitosis

Fusospirochetal

Primary pathogens of vincent’s angina

Mixture of Borrelia vincentii and Fusobacterium

High emotional stress, poor oral hygiene and smoking, nutritional deficiencies

Risk factors of vincent’s angina

Periodontal destruction and noma (cancrum oris)

Complications of Vincent’s angina

Oral debridement, pain management, infection control, hygiene education, stress reduction

Nursing management of vincent’s angina

Saliadenitis

Inflammation of the salivary glands

Pain, swelling, purulent discharge

Dehydration, radiation therapy, stress, malnutrition, salivary gland calculi (stones, sialolithiasis), improper oral hygiene

Causes of sialadenitis

S. aureus (most common) and methicillin resistant S. aureus

Pathogens of sialadenitis

Massage, hydration, warm compress, sialagogues

Massage of sialadenitis

Chronic Sialadenitis

Due to decreased salivary flow

Sialendscopy; instillation of antibiotics, corticosteroids; irrigation

Management of chronic sialadenitis

Surgical drainage and excision of the gland and duct

For recurrent sialadenitis or refractory to antibiotics

Achalasia

Absent or ineffective peristalsis of the distal esophagus + failure of the esophageal sphincter (LES) to relax

Regurgitation, noncardiac chest/epigastric pain, pyrosis

Dysphagia

Hallmark sign of achalasia

• X-ray studies

• Barium swallow

• CT scan of the chest

• Endoscopy

Assessment and diagnostic of achalasia

Bird’s beak deformity

X-ray finding of achalasia

High resolution manometry

Confirmatory test of achalasia

Lifestyle

Botulinum Toxin (Botox) injection

Pneumatic Dilation

Heller myotomy

Per-oral endoscopic myotomy

Medical and surgical management of achalasia

Gastroesophageal Reflux Disease

a common disorder marked by the backflow (reflux) of gastric or duodenal contents into the esophagus

• Pyrosis (heartburn), regurgitation, dyspepsia, dysphagia, odynophagia, hypersalivation.

• Incompetent lower esophageal sphincter

• Pyloric stenosis or motility disorders

• Hiatal hernia

Causes of excessive reflux

• Incidence increases with aging.

• Linked to tobacco use, coffee drinking, alcohol

consumption, and H. pylori infection.

• IBS and obstructive

airway disorders (Asthma, COPD, Cystic

Fibrosis)

Associations and risk factors

Ambulatory pH monitoring

Gold standard of GERD

Proton Pump Inhibitors Trial

To see if GERD symptoms resolve

Endoscopy/Barium Swallow

Evaluate mucosal damage, strictures, hernias for GERD

Nissen Fundoplication Surgery

Surgical intervention of GERD

Antacids

Neutralizes existing stomach acid

• C. Difficile

Calcium carbonate, magnesium hydroxide, alginate

Examples of antacids

H2 Receptor Antagonists

Decreases gastric acid production

• Monitor for QT-prolongation in patients with kidney injury. Dilute IV doses and administer over at least 2 mins

Famotidine, cimetidine

Key examples of H2 Receptor antagonists

Proton Pump Inhibitors (PPIs)

Decreases gastric acid production (First-line)

• may increase risk of hip fractures. Interferes with Vitamin B12, Iron, Magnesium absorption

Pantoprazole, omeprazole, esomeprazole

Examples of proton pump inhibitors

Prokinetic agents

Accelerates gastric emptying

• Tardive dyskinesia - involuntary movements

• Short term us

Metclopramide

Example of prokinetic agents

Surface agents

Preserves and protects the mucosal barrier

• give on an empty stomach (1 hr before or 2 hrs after meals).

• Separate from antacids by 30 mins

Sucralfate

Examples of surface agent

Reflux inhibitors

• stimulates the parasympathetic system

• Do not use with GI obstruction or peptic ulcers

• Urinary retention - primary use

Bethanechol chloride

Example of reflux inhibitors

TLESR inhibitors

Reduces transient LES relaxations

• used primarily when PPI therapy fails. It is a GABA-B agonist

Baclofen

Example of TLESR inhibitors

Esophageal Diverticulum

Out-pouching of mucosa and submucosa that protrudes through a weak portion of the musculature of the esophagus

• dysphagia, fullness in neck, belching, regurgitation of undigested food, gurgling noises after eating, halitosis

Pharngoesophageal

Upper esophageal diverticulum

Midesophageal

Middle esophageal diverticulum

Epiphrenic

Lower esophageal diverticulum

Zenker Diverticulum

Most common type of esophageal diverticulum, located in the pharyngoesophageal area, pulsion diverticulum

Midesophageal diverticula

• Uncommon

• Symptoms are less acute

• Condition does not require surgery

Epiphrenic diverticula

• Larger diverticula in the lower esophagus just above the diaphragm

• Related to improper functioning of the lower esophageal sphincter or to motor disorders of the esophagus

Intramural diverticulosis

Occurrence of numerous small diverticula associated with a stricture in the upper esophagus

Epiphrenic diverticula

• Larger diverticula in the lower esophagus just above the diaphragm

• Related to improper functioning of the lower esophageal sphincter or to motor disorders of the esophagus

Intramural diverticulosis

• occurrence of numerous small diverticula associated with a stricture in the upper esophagus

Barium swallow, manometric studies, esophagoscopy

Assessment and diagnostic findings of esophageal diverticulum

Endoscopic septotomy, POEM, myotomy of cricopharyngeal muscle

Management of esophageal diverticulum

Evidence of leakage from esophagus and developing fistula, foods/fluids withheld until x-ray studies show no leakage at the surgical site, begin with liquid and progress as tolerated

Nursing management of esophageal diverticulum

Hiatal Hernia

• opening in the diaphragm through which the esophagus passes becomes enlarged, and part of the upper stomach moves up into the lower portion of the thorax

Sliding esophageal hernia

The upper stomach and gastroesophageal junction have moved upward and slide in and out of the thorax

• pyrosis, regurgitation, dysphagia, intermittent epigastric pain or fullness after eating, large hiatal hernias: associated with GERD

Paraesophageal hernia

All or part of the stomach pushes through the diaphragm next to the gastroesophageal junction

• hemorrhage, obstruction, volvulus, strangulation

X-ray studies, barium swallow, esophagogastroduodenoscopy (EGD), esophageal manometry, chest CT scan

Assessment and diagnostic findings of hiatal hernias

Small frequent feedings, patient advised not to recline after 1 hour after eating, elevate head of bed on 4- to 8- inch (10-20 cm)

• manage nausea and vomiting

• Diet starts liquids to solids

• Tracking nutritional intake

• Monitor weight

• WOF: bleching, vomiting, gagging, abdominal distention, epigastric chest pain

Management of hiatal hernias

Esophageal Varices

Result from portal hypertension, typically due to liver cirrhosis, where obstruction of blood flow through the liver causes pressure to build in the portal venous system.

Upper endoscopy

Gold standard for esophageal varices and to directly visualize, grade, and treat dilated veins in the esophagus

• Acute bleeding management: IV fluids, blood transfusion, IV octreotide, endoscopic variceal band ligation, prophylactic antibiotics (Ceftriaxone), TIPSS Procedure

• Prophylaxis - non selective beta blockers (nadolol or propranolol)

Management of esophageal varices