GERD/Hiatal Hernia

What is GERD?

a symptom of mucosal damage caused by reflux of stomach acid into the lower esophagus

Is GERD most commonly upper or lower GI?

Upper GI

What acid is refluxed from the stomach in GERD?

gastric acid, pepsin, trypsin, bile

Esophagitis 

Irritation and inflammation of the esophagus caused by gastric acid and reflux 

What increases your risk of having GERD?

Obesity

What is the cause of GERD?

A weak (incompetent) lower esophageal sphinchter (LES)

What does a weak lower esophageal sphincter do?

lets gastric contents move from stomach to esophagus when pt is supine or has increased abdominal pressure 

What medications contribute to GERD

Anticholinergics

Beta blockers 

Calcium channel blockers 

Diazepam (Valium) 

Morphine sulfate 

Nitrates 

Theophylline 

Progesterone 

What substances contribute to GERD?

Alcohol

Smoking 

Caffeine

What foods contribute to GERD?

Chocolate

Fatty food

Peppermint/Spearmint  

How does peppermint/spearmint contribute to GERD?

Weakens the lower esophageal sphincter 

What are clinical manifestations of GERD?

Pyrosis

Dyspepsia 

Regurgitation 

Respiratory symptoms - wheezing, coughing, dyspnea 

Hoarseness, lump in throat, choking 

What is pyrosis?

Heartburn 

What is dyspepsia?

Pain or discomfort in the upper abdomen

Why are antacids not a permanent solution for GERD?

Antacids “mask” symptoms by neutralizing acid, and does not solve underlying problem

How often is pyrosis experienced with GERD?

Persistent mild symptoms more than twice a week

Moderate/severe symptoms once a week

What clinical manifestations of GERD require evaluation by a HCP?

Severe heartburn

Heart burn more than 2x a week

Heartburn with dysphagia 

Occurs at night 

Awakens you from sleep 

Older person with recent onset of heartburn 

What are complications of GERD?

Esophagitis

Ulcers 

Barrett esophagus (BE) 

Fibrosis, scarring 

What is Barrett esophagus (BE)?

cellular changes

Epithelium substituted for squamous epithelium

What are risk factors for BE?

Central obesity

>60 years old

White men 

What is fibrosis?

Excessive accumulation of fibrous connective tissue

What can fibrosis result in?

Strictures

Dysphagia 

What are strictures?

The narrowing/constriction of esophagus 

What are diagnostic studies done for GERD?

Endoscopy

Biopsy 

Manometric studies 

Esophageal pH monitioring 

What does an endoscopy assess?

LES competence 

Inflammation, scarring, and strictures

What is the normal pH of the esophagus?

4-7

What is the normal pH of the stomach?

1.5-3.5

What does a biopsy assess?

Dysplasia

Distinguishes stomach/esophageal cancer from BE 

What is dysplasia?

An abnormal change in the size, shape, or organization of cells in a tissue/organ

What angle should the HOB be to prevent GERD?

30 degrees

How could you elevate the head by 30 degrees?

Pillows or 4 to 6 inch blocks

How long should you avoid laying down after a meal?

2-3 hours

What type of clothing should you avoid to prevent GERD?

Tight clothing around the wait 

If you drop something, you should avoid ____ to prevent GERD

Bending over at the waist

When should you stop eating before bedtime?

3 hours

What are other lifestyle modifications to prevent GERD?

Reduce stress

Stop smoking 
Reduce weight 

Increase physical activity 

Low-fat diet

Eat 4-6 small meals per day

How does stress increase the risk of GERD?

Stress increases cortisol, which increases acid

How does increasing physical activity help prevent GERD?

Increases GI motility

Decreases obesity 

What beverages should you avoid to prevent GERD?

Alcohol

Caffeine 

Cola

Red wine 

Acidic beverages (Citrus juice) 

What does drug therapy for GERD help to do?

Decrease volume and acidity of reflux

What medications can be used to treat GERD?

H2 Receptor Blockers

Proton Pump Inhibitors 

What is an example an H2 blocker?

Famotidine (pepcid)

What is an example of a proton pump inhibitor?

Omeprazole (Prilosec OTC)

What do H2 receptor blockers do?

Reduce acid production

What do proton pump inhibitors do?

Block acid production

What is the onset/duration of H2 receptors?

Onset - 1 hour 

Duration - 12 hours

Can you combine a H2 blocker or Proton pump inhibitors with antacids?

Yes

How should you take proton pump inhibitors?

Once daily before the first meal of the day

What works better - H2 receptor blockers or PPI’s?

PPI’s

What are longterm complications of PPI’s?

Decreased bone density

Kidney disease

Vitamin B12

Magnesium deficiency

What are two examples of adjunct medications for GERD?

Antacids

Prokinetics 

What do antacids do?

Neutralize acids

When should you take antacids? What is the onset/duration?

1-3 hours after meals and at bedtime

Effects last for 3-4 hours

Relieves heartburn in 20-30 minutes

What is an example of a prokinetic?

Metoclopramide (Reglan)

What do prokinetics do?

Increase LES pressure

Increase gastric emptying 

Increase gastric motility 

What foods decrease LES pressure?

Chocolate, peppermint, fatty foods, coffee, tea

What do late evening meals, nighttime snacking, and milk before bedtime result in?

Increased gastric acid secretion

How do you prevent stomach distention?

Small frequent meals

Drink fluids between meals 

Does stomach distention increase the risk of GERD?

Yes

Does chewing gum effect acid reflux?

Helps mild symptoms 

What is the goal of Laparoscopic Surgical Therapy?

Enhance LES integrity

Protect against reflux

What is a fundoplication?

Wraps fundus of the stomach around the esophagus

Tightens esophageal sphincter

What is a side effect of a fundoplication during the first month postoperatively?

Dysphagia for the first month post op 

What is the LINX Reflux Management System?

Magnets in titanium beads connected by titanium wires to help keep the LES closed

What test can a pt with a LINX NOT have?

MRI

What are complications someone with a LINX might encounter?

Nausea, swallowing problems, pain when swallowing food

What are alternatives to surgery to treat GERD?

Endoscopic mucosal resection 

Radiofrequency ablation

What does an Endoscopic Mucosal Resection do?

Removes abnormal tissue from the esophagus to treat BE or early cancer that can develop as a result of GERD

What does Radiofrequency Ablation do?

Uses heat energy that creates lesions to thicken the LES

What is a Hiatal Hernia?

Portion of the stomach protrudes up through the opening in the diaphragm

Type 1 sliding hernia

The junction of the stomach and esophagus is above the diaphragm when supine

What happens to a sliding hernia when standing?

Goes back to the abdominal cavity

Type 2 rolling hernia 

Fundus of the stomach goes through the diaphragm 

Forms a pocket alongside the esophagus 

What are symptoms of a Sliding (Type 1) hernia?

Acid reflux (Barretts esophagitis)

Strictures 

Dysphagia 

Erosion (Cameron lesion) 

What are symptoms of a Rolling (type 2) hernia?

Fullness after eating

Breathless after eating

Chest pain 

Volvus/Obstruction 

What causes a hiatal hernia?

Weakening of muscles in the diaphragm

Aging 

Increased intrabdominal pressure

What increases intrabdominal pressure

Obesity

Pregnancy 

Ascites 

Tumors 

Physical exertion 

Heavy lifting 

What are the clinical manifestations of a hiatal hernia?

Comparable to GERD

What are complications of a hiatal hernia?

Esophagitis

Bleeding from erosion 

Stenosis 

Ulceration of herniated portion of the stomach 

Strangulation of hernia 

Regurgitation with tracheal aspiration 

What are ways to manage hiatal hernia’s?

Reduce intrabdominal pressure

No constricting clothing 

No lifting/straining 

Antacids 

H2 receptor blockers 

Proton pump inhibitors 

When is surgery needed for hernias?

Large symptomatic sliding (type 1)

All cases of type 2 (rolling)

What are laparoscopic surgeries for hernias?

Nissen/Toupet fundoplication

Top of stomach wrapped around the esophagus 

What are open surgeries for hernias?

Gastropexy (attach stomach below diaphragm) 

Herniotomy (remove herniated sac) 

Herniorrhaphy (repair/close hiatal defect) 

What should you assess for a pt with a hernia?

Heartburn 

Regurgitation 

Dysphagia 

Belching 

Breathlessness 

Nonpharmacologic interventions for hernias 

Sleep with HOB elevated

Lose weight 

Avoid tobacco and alcohol 

Reduce stress 

Why do older adults have an increased risk for hernias?

Weakened diaphragm

Obesity 

Kyphosis increases intrabdominal pressure (excessive outward, rounded curve of spine) 

Takes meds that decrease LES pressure

What medications decrease LES pressure?

Nitrates

Calcium channel blockers 

Antidepressants