CASE STUDY

Patien Particular

Name Of Patien : Mr. L B S

I/C Number : B7378776
Age : 46
Gender : Male
Race : China
Mariatal Status : Married
Children :2
Occupation : Bissunisman
Address : Serawak, Malaysia
Ward :
Date Of Admission : 14/11/2019 15:03
Date Of Discharge : 15/11/2019 08:30
Diagnosis : Hiatus Hernia Gastric
Allergies : N/A

Case Scenario
Patien come to hospital with stomach pain after food and discomfort gastric (Duration
rectal sternal discomfort), feel vomiting and ask for condition check. Patient was
complaining of vomiting for 6 episode in a day. Patien complain that hunger feeling
increase more then before so that his weight is up.
Patien vital sign were taken as table below

Blood Pressure 110/70

Heart Rate 60
Respiration Rate 20
Temperature 36℃

After checking vital sign, the patient tell about his medical history. Patient was being
seen by doctor in the ward and able to proceed for OGDS (oesopaghus
Doedenouscopy) as planed. For a while, patient suspected GERD indication, so that
the patient will be processed in OGDS.

Allergy :
N/A

History of present illness :

Acid Reflux on + off
Heart Burn
Pain after food
No OGDS before

Present Medication :
Anti Depression

Past Medical History :

Sinus Surgery
No other Surgery
No Medical illnes

Social / Family History

- No Smoking
- No Coffee
- No Family History Cancer

Life Style in past :

- 6 year ago patient always using drugs and alcohol.
- After 3 year his job is break down and low financial.
- After that he get stress and gastits. Get antidepression medication in psyciatrik
doctor .
Diaphragm anatomy and function
The diaphragm is a thin skeletal muscle that sits at the base of the chest and separates
the abdomen from the chest. It contracts and flattens when you inhale. This creates a
vacuum effect that pulls air into the lungs. When you exhale, the diaphragm relaxes
and the air is pushed out of lungs.
It also has some nonrespiratory functions as well. The diaphragm increases abdominal
pressure to help the body get rid of vomit, urine, and feces. It also places pressure on
the esophagus to prevent acid reflux.
The phrenic nerve, which runs from the neck to the diaphragm, controls the movement
of the diaphragm.
There are three large openings in the diaphragm that allow certain structures to pass
between the chest and the abdomen.
These openings include the:
 Esophageal opening. The esophagus and vagus nerve, which controls much
of the digestive system, pass through this opening.
 Aortic opening. The aorta, the body’s main artery that transports blood from
the heart, passes through the aortic opening. The thoracic duct, a main vessel
of the lymphatic system, also passes through this opening.
 Caval opening. The inferior vena cava, a large vein that transports blood to
the heart, passes through this opening.

Anterior View Posterior View

Diaphragm conditions
A range of health conditions can affect or involve the diaphragm.
Hiatal hernia
A hiatal hernia happens when the upper part of the stomach bulges through the
esophageal opening of the diaphragm. Experts aren’t sure why it happens, but it could
be caused by:
 age-related changes in the diaphragm
 injuries or birth defects
 chronic pressure on surrounding muscles from coughing, straining, or heavy
lifting
They’re more common in people who are over the age of 50 or obese.
Small hiatal hernias usually don’t cause any symptoms or require treatment. But a
larger hiatal hernia may cause some symptoms, including:
 heartburn
 acid reflux
 trouble swallowing
 chest pain that sometimes radiates to the back
Larger hiatal hernias sometimes require surgical repair, but other cases are usually
manageable with over-the-counter antacid medication. Proton pump inhibitors can
also help to reduce acid production and heal any damage to the esophagus.
Diaphragmatic hernia
A diaphragmatic hernia happens when at least one abdominal organ bulges into the
chest through an opening in the diaphragm. It’s sometimes present at birth. When this
happens, it’s called a congenital diaphragmatic hernia (CDH).
Injuries from an accident or surgery can also cause a diaphragmatic hernia. In this
case, it’s called an acquired diaphragmatic hernia (ADH).
Symptoms can vary depending on the size of the hernia, the cause, and the organs
involved. They may include:
 difficulty breathing
 rapid breathing
 rapid heart rate
 blueish-colored skin
 bowel sounds in the chest
Both an ADH and CDH require immediate surgery to remove the abdominal organs
from the chest cavity and repair the diaphragm.
Cramps and spasms
A diaphragmatic cramp or spasm can cause chest pain and shortness of breath that can
be mistaken for a heart attack. Some people also experience sweating and anxiety
during a diaphragm spasm. Others describe feeling like they can’t take a full breath
during a spasm.
During a spasm, the diaphragm doesn’t rise back up after exhalation. This inflates the
lungs, causing the diaphragm to tighten. This can also cause a cramping sensation in
the chest. Vigorous exercise can cause the diaphragm to spasm, which often results in
what people call a side stitch.
Diaphragm spasms usually go away on their own within a few hours or days.
Diaphragmatic flutter
Diaphragmatic flutter is a rare condition that’s often mistaken for a spasm. During an
episode, someone might feel the fluttering as a pulsing sensation in the abdominal
wall.
It can also cause:
 shortness of breath
 chest tightness
 chest pain
 abdominal pain
Phrenic nerve damage
Several things can damage the phrenic nerve, including
 traumatic injuries
 surgery
 cancer in the lungs or nearby lymph nodes
 spinal cord conditions
 autoimmune disease
 neuromuscular disorders, such as multiple sclerosis
 certain viral illnesses
Anatomy and physiology of the stomach
The stomach is a muscular, J-shaped organ in the upper part of the abdomen. It is part
of the digestive system, which extends from the mouth to the anus. The size of the
stomach varies from person to person, and from meal to meal.

Structure
The stomach is part of the digestive system and is connected to the:
 esophagus – a tube-like organ that connects the mouth and throat to the
stomach. The area where the esophagus joins the stomach is called the
gastroesophageal (GE) junction.
 small intestine (small bowel) – a long tube-like organ that extends from the
stomach to the colon (large intestine or large bowel). The first part of the small
intestine is called the duodenum, and it is this part that is connected to the
stomach.
The stomach is surrounded by a large number of lymph nodes.
Regions of the stomach
The stomach is divided into 5 regions:
  The cardia is the first part of the stomach below the esophagus. It contains the
cardiac sphincter, which is a thin ring of muscle that helps to prevent stomach
contents from going back up into the esophagus.
 The fundus is the rounded area that lies to the left of the cardia and below
the diaphragm.
 The body is the largest and main part of the stomach. This is where food is
mixed and starts to break down.
 The antrum is the lower part of the stomach. The antrum holds the broken-
down food until it is ready to be released into the small intestine. It is
sometimes called the pyloric antrum.
 The pylorus is the part of the stomach that connects to the small intestine. This
region includes the pyloric sphincter, which is a thick ring of muscle that acts
as a valve to control the emptying of stomach contents (chyme) into the
duodenum (first part of the small intestine). The pyloric sphincter also prevents
the contents of the duodenum from going back into the stomach.

Layers of the stomach wall

The stomach is made up of several layers of tissue:
 The mucosa (mucous membrane) is the inner lining of the stomach. When the
stomach is empty the mucosa has a ridged appearance. These ridges (rugae)
flatten out as the stomach fills with food.
  The next layer that covers the mucosa is the submucosa. It is made up of
connective tissue that contains larger blood and lymph vessels, nerve cells and
fibres.
 The muscularis propria (or muscularis externa) is the next layer that covers the
submucosa. It is the main muscle of the stomach and is made up of 3 layers of
muscle.
 The serosa is the fibrous membrane that covers the outside of the stomach. The
serosa of the stomach is also called the visceral peritoneum.
Function
The stomach has 3 main functions:
 temporary storage for food, which passes from the esophagus to the stomach
where it is held for 2 hours or longer
 mixing and breakdown of food by contraction and relaxation of the muscle
layers in the stomach
 digestion of food
The mucosa contains specialized cells and glands that produce hydrochloric acid and
digestive enzymes to help digest food. The mucosa in the cardiac and pyloric regions
of the stomach release mucus that helps protect the lining of the stomach from the acid
produced for digestion. Other specialized cells in the mucosa of the pylorus release
the hormone gastrin into the blood. Gastrin helps to stimulate the release of acid and
enzymes from the mucosa. Gastrin also helps the muscles of the stomach to start
contracting.
Food is broken down into a thick, acidic, soupy mixture called chyme. The pyloric
sphincter relaxes once chyme formation is complete. Chyme then passes into the
duodenum. The duodenum plays a big role in absorption of the food we eat. The
stomach does not play a big role in absorption of food. It only absorbs water, alcohol
and some drugs.

A. Basic Concepts of Disease

1. understanding
The word hernia comes from the Latin, herniae, which means
protrusion of the contents of a cavity through thin connective tissue weak
(defects) in the wall cavity, either congenital or acquired, which provide a
way out in any organ other than the usual through the wall ( Mansjoer,
2009).
Hiatal hernia is an abnormal protrusion of the stomach proximal
esophagus in the diaphragm through the door that led to a more proximal
position esofagogaster connection and predispose to the occurrence of
gastroesophageal reflux disease (GERD) (Pierce, 2007).
Hiatal hernia is a herniation of the proximal part of the stomach
to the chest, which is caused by a defect in the diaphragm congenital or
acquired. These abnormalities could predispose to gastroesophageal reflux
of acidic stomach contents and inflammation of the distal third of the
esophagus (reflux esophagitis) or gastric metaplasia (Barrett's epithelium)
(Davey, 2006).
From the definition above can be concluded that the hernia is a
condition in which the sphincter cardia be wide open so as to allow part of
the stomach into the thorax.
Classification according Lusianah hernia and Suratun (2010)
are as follows:
a. Hernia classification according to location:
1) inguinal hernia
Definition of inguinal hernias according Generous and
Rahayuningsih (2010) is the prominence of the contents of a
cavity through the inguinal ring located on the lateral inferior
epigastric vaso down the inguinal canal and out into the
abdominal cavity through the external inguinal ring.
Meanwhile, according Nurarif and Kusuma (2013), inguinal
hernia is a hernia the most common and appears as a bulge in
the groin or scrotum.
According Lusianah and Suratun (2010), inguinal hernias are
divided into:
a) Indirect or lateral hernias
This hernia occurs through the inguinal ring and
spermatikus cord passes through the inguinal canal, can
be large and often comes down to skrotum.Umumnya
occur in men, the lump can shrink, disappear during sleep
 and crying, straining, lifting heavy objects or stand can
grow back ,
b) Hernia direct or medial
These hernias of the abdominal wall in the area past the
muscle weakness, not through channels such as the
inguinal and femoral hernia indirek.Lebih common in the
elderly. A hernia is called direkta because it directly
towards the external inguinal ring so despite the internal
inguinal arteries pressed when the client standing or
straining, still there will be bumps. On the client looks a
round mass in the external inguinal arteries shrink when a
client that is easy to sleep. Because of the large defect in
the posterior wall of the hernia is rarely irreponibel.
2) femoral hernia
Femoral hernias occur through the femoral ring and is more
common in wanita.Ini began as a cap for the femoral dikanalis
enlarged fat and gradually pull peritoneum and almost
unavoidable bladder into the bag.
3) umbilical hernia
The umbilical hernia usually occurs in women due to
increased abdominal pressure, usually on the client obese and
multiparous.
4) incisional hernia
Incisional hernia occurs in the previous surgical incision has
healed is inadequate, impaired wound healing may be caused
by infection, inadequate nutrition, or obesity ekstem
distension, bowel or other organs protrude through the weak
scar tissue.
5) Sliding hernia
Sliding hernia occurs when the condition of the cardia spingter
enlarged, allowing one part of the stomach cavity of the piston.
On the upper hull sliding hernia and gastroesophageal meeting
changed the place into the piston. Reflux appears to be caused
 by lower esophageal sphincter Exposure (SEB) at low
pressure in the thorax. The main problem with respect to the
sliding hernia is the occurrence of reflux. In the sliding hernia,
SEB remained below the diaphragm so that reflux is not a
problem.
6) Hiatal hernia
Esophageal hiatal hernia is a hole enter the abdomen through
the diaphragm, and the empties at the lower end of the state of
the upper stomach. Normally, the hole in the diaphragm
surrounding the esophagus tightly, and stomach were halved
in the abdomen. In a condition called hiatal hernia diaphragm
hole passing through the esophagus becomes enlarged and the
top of the stomach tend to stir up the bottom of the piston.
Hiatal hernia occurs more often in women than men.
Regurgitation and motor dysfunction causing major
manifestation of hiatal hernia. Hiatal hernia complications
include obstruction, strangulation, and the occurrence of
volvulus.
b. Classification is based on the occurrence of hernia:
1) Congenital hernia (congenital)
Congenital hernias occur in fetal growth over the age of three
weeks early testes located above decreased (desensus) heading
into the scrotum. At the time of passing through the inguinal
testes descend to the scrotum peritoneal processus vaginalis
open and relate to undergo peritoneal cavity obliteration and
after testes in the scrotum, processus vaginalis peritoneal
entirely covered (obliteration). When there is interference
obliteration of the entire processus vaginalis peritonela open,
there was a lateral inguinal hernia.

2) Hernia akuisitas (acquired)

Hernias that occur after the adults or the elderly. Due to the
increased intra-abdominal pressure and for a long time, such
 as chronic cough, chronic constipation, urinary processing
disorder (prostatic hypertrophy, urethral stricture), ascites, and
so on.
c. Hernia classification according to its nature:
1) hernia reponibel
If the hernia contents can be out, gut out when standing or
straining and sign in again when lying down or pushed in,
there is no pain or symptoms of bowel obstruction.
2) hernia irreponibel
If the hernia contents of the bag can not be returned into the
contents of the bag cavity for peritoneal adhesions hernia bag,
no complaints of pain / signs of bowel obstruction, hernia
hernia is also called accreta.
3) Strangulan or incarcerated hernia
If the hernia contents pinched by a ring of hernia, the contents
of the bag is trapped, unable to get back into the abdominal
cavity due to the form of interference with the passage or
vascularization.
d. According Generous and Rahayuningsih (2010), hernia
classification based on its content:
1) Adipose hernia, hernia contents that fat tissue.
2) Standing hernia, the hernia contents back part of the bag wall
hernia.
3) Hernia litter, incarcerated hernia / strangulated partially
wedged in the gut wall hernia ring
2. Etiology
According Generous and Rahayuningsih (2010), etiology or
factors that lead to hernia are:
a. abdominal weakness
Weak abdominal wall can be caused by a congenital defect or a state
obtained after birth and age can affect the abdominal wall weakness
(increasing age weakened abdominal wall).
b. Increased intra-abdominal pressure
 Lifting heavy objects, chronic cough, pregnancy, obesity and
excessive exercise.
c. Inborn
At the age of 8 months of pregnancy decreased testis through the
inguinal canal and called plekus interesting peritoneus vaginalis,
peritoneal inguinal hernia because the canal will remain shut at 2
months of age.
d. Habits lifting heavy objects (heavy lifting)
e. Obesity
f. Cough
g. Straining during bowel movements are too small / large
h. There is fluid in the abdomen (ascites)
i. peritoneal dialysis
j. Ventriculo peritoneal shun
k. Chronic obstructive pulmonary disease (COPD)
l. Family history is suffering from hernia
Hiatal hernia itself can occur because:
a. Increased intra-abdominal pressure.
Many factors can increase intra-abdominal pressure. Some
patients have a hiatal hernia after an abdominal injury. High-intensity
abdominal pressure such as coughing or severe vomiting, pregnancy,
obesity, intra-abdominal fluid, or lifting heavy objects increases
impetus and a risk of hiatal hernia.
b. Congenital weakness.
Congenital defects in cardiac sfinter give predisposition
weakening of this section, with an increase in intra-abdominal pressure,
then the condition of hiatal hernia becomes meningakat.
c. Increasing age
Muscle weakness and loss of elasticity in the elderly increases
the risk of hiatal hernia. With the weakening of elasticity, which is open
cardiac sphincter is not retraced to normal. In addition, the diaphragm
muscle weakness also paves the way masukknya hull into the thoracic
cavity.
d. structural abnormalities
 e. Gastro-oesophageal reflux is mainly caused by lifestyle factors, obesity
increases intra-abdominal pressure. Smoking, stress and dietary factors
(eg fatty foods, pastries, alcohol, chocolate) all reduce the pressure on
the lower esophageal sphincter and cause reflux (Davey, 2006).
3. pathophysiology
The esophagus passes hiatus crural diaphragm at the diaphragm to
reach the stomach. The diaphragmatic hiatus itself is about 2 cm and
consists primarily of musculotendinous slip of the right and left crura
diaphragm arising from both sides of the spine and passing around the
esophagus before inserting into the central tendon of the diaphragm.
Hiatus size is not fixed, but narrows whenever increased intra-abdominal
pressure, such as when lifting weights or cough.
Lower esophageal sphincter (LES) is an area of approximately 2.5
to 4.5 cm of smooth muscle that is normally always in the intra-abdominal
or below the diaphragmatic hiatus. In this condition the visceral
peritoneum and ligaments frenoesofageal cover the esophagus.
Frenoesofagus ligament is the connective tissue of the crura of the
diaphragm for maintaining the LES in the abdominal cavity.
Conditions sudden increase in intra-abdominal pressure will act
on the LES under the diaphragm to increase the pressure of the sphincter
in order to prevent reflux of gastric contents into the esophagus.
Action of the gastroesophageal junction as a barrier to prevent
gastroesophageal reflux with antireflux barrier combination mechanism
consisting of a diaphragmatic crura, LES pressure, and intra-abdominal
segment, as well as his stimulus. Adannya condition of hiatal hernia will
result in a barrier to antireflux does not happen, the pressure drop of the
LES, and also decrease the acid clearance by the esophagus so that the
esophageal mucosa becomes more frequent contact with stomach fluids
and increase the risk of inflammation of the gastric mucosa with various
manifgus that esophageal mucosa becomes more frequent contact with the
gastric juices and increases the risk of gastric mucosal inflammation with
different clinical manifestations will occur (Peter J et al, 2008).
4. Clinical manifestations
Clinical manifestations and Rahayuningsih hernia according
Benefactor (2010):
a. Without complaint (asymptomatic)
b. Slightly protruding hernia area, grew especially when standing
c. Pain and fever
d. Sudden pain in hernia
e. Generalized abdominal pain
f. Nausea and vomiting
g. Hernia tense, tenderness
According to Davey (2006), hiatal hernia clinical
manifestations that may arise are as follows:
a. Heartburn (heartburn), can be a major complaint and cause spasm of
the esophagus. This complaint is very similar to angina.
b. Transient dysphagia, esophagitis can be experienced on weight.
Dysphagia is more persistent regurgitation or vomiting suggests the
development of secondary complications such as peptic esophageal
stricture or even carcinoma.
5. Diagnostic
According Kluwer, Williams & Wilkins (2012) diagnostic
examinations for clients with a hiatal hernia is as follows:
a. Laboratory
1) Serum hemoglobin and hematocrit levels decreased in patients
hernia paraesofagus, if there is bleeding from esophageal
ulceration
2) Occult blood test can be positive
3) The analysis of stomach contents showed the presence of blood
b. photography
1) Chest X-ray showed a shadow behind the heart in the air in a
large hernia; lower lobe infiltration at the time suffered
aspirations
2) Barium swallow with fluoroscopy test detects the presence of a
hiatal hernia and diaphragmatic abnormalities
c. diagnostic procedures
 1) Results endoscopy and biopsy
Identifying the link mucosa and diaphragm hollowed edge
towards the esophagus; distinguish hiatal hernia, varicose veins,
erosion, ulcers, Barrett esophagus and gastroesophageal that
other small lesions; and eliminate the possibility of a malignant
tumor
2) Esophageal motility studies indicate the movement of the
esophagus or abnormal lower esophageal pressure before
surgery on a hernia repair
3) PH analysis identifies reflux of stomach contents
4) Acid perfusion test (Bernstein) shows oesophageal reflux
According Lusianah and Suratun (2010), the diagnostic test in
patients with hernia are:
a. CBC: show an increase in white blood cells, serum electrolytes may
indicate hemoconcentration (increased hematocrit), and electrolyte
imbalance. Examination of blood coagulation: be elongated, affect
the homeostasis intra- or postoperative surgery.
b. Urine examination: the appearance of red blood cells or bacteria that
indicate infection.
c. Electrocardiography (ECG)
The invention will be something that is not normal to give priority
attention to give anesthesia.
d. Abdominal X-ray showed severe abnormalities in the levels of gas
in the intestine or bowel obstruction.
6. complication
Some of the complications that can arise by Kluwer, Williams
& Wilkins (2012) are:
a. esophageal stricture
b. Inkarserata (hernia paraesofagus)
c. Associated with gastroesophageal reflux disease:
1) esophagitis
2) Ulceration and perforation of the esophagus
3) hemorrhage
4) peritonitis
 5) mediastinitis
6) aspiration
7) Strangulation and gangrene in the stomach herniated
d. Iron deficiency anemia
e. chronic cough
f. dysphagia
7. Management
Medical management by Price & Borley (2007) are:
a. Sandat usage ( "truss")
This tool is only used for patients - patients who are very advanced
age or keadanya weak. Sandat One type consists of a strong spring
and pads are placed on the neck of the hernia so that the neck is
always closed by the pressure after the hernia contents is returned to
its place (repositioned).
b. Surgery
Neck hernia is closed with sutures and pocket excised. The stretched
tissue repaired with one of the many materials available.
c. Nissen fundoplication which can be either trans abdominal or trans-
thoracic where the action is to be around 360 degrees fundoplication
between the distal esophagus and gastric fundus. prognosis of
success 96%
d. Belsey (Mark IV) fundoplication : By transthoracic until you see
intra-abdominal esophagus, later reinforced by means of a gastric
application in circumference of 270 degrees to the distal esophagus.
e. herniotomy
Hernianya sac excision alone for pediatric patients.
f. herniorafi
Disposing of the hernia bag with plastic surgery to strengthen the
lower abdominal wall behind the inguinal canal.
g. Fixing defek- improvements with the installation of nets (mesh) usual
for inguinal hernia, which is inserted through open or laparoscopic
surgery.
Management of nursing by Kluwer, Williams & Wilkins
(2012), namely by providing health education that includes:
 a. Efforts to avoid heavy lifting activity and straining for defecation
b. Postoperative wound care
c. After the surgery, do not perform normal activities or return to work
without a permit surgeons

B. Basic Concepts of Nursing

1. assessment
a. demography
Hiatal hernia occurs more often in women than men.
Regurgitation and motor dysfunction causing major manifestation of
hiatal hernia.(Lusianah & Suratun, 2010). Hernias often happens to
workers who are carrying heavy objects, straining too strong during
urination / large, pregnancy, obesity, chronic cough, and can
jugadisebabkan congenital abnormalities (Generous and
Rahayuningsih, 2010).
Muscle weakness and loss of elasticity in the elderly increases
the risk of hiatal hernia. With the weakening of elasticity, which is
open cardiac sphincter is not retraced to normal. In addition, the
diaphragm muscle weakness also paves the way masukknya hull into
the thoracic cavity.
Assessment of hiatal hernia, according Sjamsuhidayat and Jong
(2011) consists of assessment history, physical examination, and
diagnostic evaluation.

a. anamnesis
1) Main complaint
In anamnesis main complaint is a complaint commonly found
associated with the condition of gastroesophageal reflux and
gastric acid contacts the esophageal mucosa are on complaints
of chest pain (retrosternal).
2) History of present illness
In hiatal hernia usually existing complaints such as heartburn
(taste very uncomfortable when food started to go after
ingestion), regurgitation (backflow of stomach contents into
 the esophagus), vomiting complaint taste sour, bitter or
unpalatable in the oral cavity, increased frequency burp, often
choking, chest feel like pressure, discomfort in the abdomen,
upper abdominal tenderness, especially after eating, sudden
cough and difficulty swallowing.
3) Past medical history
Past medical history is important to be studied is a systemic
disease, such as diabetes mellitus, hypertension, tuberculosis
is considered as a means of preoperative assessment.
4) psychosocial
In the psychosocial assessment will get increased anxiety
because of chest pain (retrosternal) and plan the surgery and
the need for compliance with preoperative information.
b. Physical examination
In a general survey of patients with hiatal hernia patient looks weak
and in pain, TTV changes secondary to pain, weight loss in patients
with symptoms of dysphagia is chronic.
According to Erickson (2009), diagnostic assessments that can help,
including the examination of tissue culture to detect tuberculosis
adenitis, plain abdominal to detect the presence of air in the intestine
and to detect the presence of ileus, and ultrasound to assess the mass
of hiatal hernia.
c. endoscopic Procedures
1. Radiographic assessment
While performing contrast barium studies of the upper
gastrointestinal tract, a globular structure termed "phrenic ampulla"
is seen above the diaphragm during swallows.32 This structure has
traditionally been Considered to be a physiologic finding, but the
study using simultaneous fluoroscopy and manometry demonstrated
that it corresponded to a small hiatal reducing hernia.16 There are
Several landmarks of the phrenic ampulla that are worth
mentioning. The upper margin of the phrenic ampulla abuts the
tubular esophagus forming a structure called the "A" ring, the which
is a muscular ring. This ring corresponds to the upper margin of the
LES. The lower margin of the phrenic ampulla is demarcated by the
diaphragmatic indentation. Within the phrenic ampulla, a mucosal
ring ( "B" ring) can be identified, the which corresponds to the
squamocolumnar junction (Zline) or the union of the esophagus
with the stomach.34 When the "B" ring is prominent, ie, the luminal
diameter of 2 cm (Fig. 1) .30,33,34 The limitation of this method is
that it is not always possible to detect all the landmarks of the
phrenic ampulla. Defining hiatal hernia Becomes especially
problematic when the "B" ring, marker Necessary for defining the
presence of a hiatal hernia that is only detectable in about 15% of
subjects, can not be identified. In the absence of the "B" ring, the
result of barium contrast studies to diagnose a hiatal hernia can
Become quite inconsistent. In this case, the upper margin of the
Rugal Folds is used instead as the reference point. In addition, the
timing of taking images can serve as a source of inaccuracy, since
the distance between the "B" ring and the diaphragmatic indentation
would vary Depending on the point of swallowing at the which the
images were taken. The lack of standardized protocols as to
Whether examination should be done in an upright or supine
position etc. Also adds to the inconsistencies in diagnosing hiatal
hernias. Furthermore, in order to observe your the relationship
between the aforementioned structures and view them under
fluoroscopy, the patient should swallow the contrast material. Since
swallowing itself distends and shortens the esophageal lumen,
diagnosing hiatal hernia <2 cm Becomes impractical with barium
contrast studies. Also adds to the inconsistencies in diagnosing
hiatal hernias. Furthermore, in order to observe your the relationship
between the aforementioned structures and view them under
fluoroscopy, the patient should swallow the contrast material. Since
swallowing itself distends and shortens the esophageal lumen,
diagnosing hiatal hernia <2 cm Becomes impractical with barium
contrast studies. Also adds to the inconsistencies in diagnosing
hiatal hernias. Furthermore, in order to observe your the relationship
between the aforementioned structures and view them under
fluoroscopy, the patient should swallow the contrast material. Since
swallowing itself distends and shortens the esophageal lumen,
diagnosing hiatal hernia <2 cm Becomes impractical with barium
contrast studies.
2. Endoscopical assessment
The use of endoscopy has Become widespread over the past few
Decades and is now Considered the standard modality for
diagnosing and treating diseases of the upper gastrointestinal tract.
Although barium contrast study has been the most commonly
applied method for diagnosing worldwide hiatal hernia, hiatal
hernia is Increasingly Diagnosed with endoscopy (Fig. 1). The most
commonly accepted diagnostic criterion of endoscopic hiatal hernia
is the proximal dislocation of GEJ of> 2 cm above the
diaphragmatic indentation. However, controversy still exists as to
the which the marker of GEJ should serve as the reference to
diagnose the presence of a hiatal hernia: SCJ, the upper margin of
the gastric folds or the distal margin of the palisade zone. Therefore,
to diagnose hiatal hernia endoscopically, endoscopic definition of
GEJ should first be clarified. SCJ is the circumferential margin that
is formed by the pinkish gray colored squamous epithelium of the
esophagus and the reddish orange colored columnar epithelium of
the stomach. This transition zone IS ALSO called the "Z-line" and
can vary in contour.35 SCJ usually corresponds to GEJ in normal
subjects and many Consider that a hiatal hernia is present when
there is separation of> 2 cm between the SCJ and the diaphragmatic
indentation .29 However in the presence of columnar-lined
esophagus or Barrett's esophagus, SCJ is moved cranially and Tus
can not serve as a reliable marker. The upper margin of the gastric
folds Generally Accepted IS ALSO A marker used to identify
GEJ.36,37 Nevertheless, endoscopists sometimes have difficulty
identifying Clearly this marker. Another option is to use the distal
margin of the palisade zone to depict the GEJ. Palisade zone is the
longitudinally parallel capillaries running underneath the most
distal 2 to 3 cm of the esophageal epithelium.38 In 1966, de
Carvalho took a special interest in this vascular anatomy and its
illustrated schematically angioarchitecture dividing it into four
distinct zones zones.39 Reviews These were later named as truncal
zone, perforating zone, palisade zone and gastric zone.40,41 Based
on this anatomy, Hoshihara the patterns of GEJ classified into four
types According to the relationship among the distal margin of the
palisade zone, SCJ and the diaphragmatic indentation.42 In the first
type, the distal margin of the palisade zone, SCJ and the
diaphragmatic indentation (or pinchcock action) all fall at the same
level. In the second type, the distal margin of the palisade zone and
the diaphragmatic indentation lie at the same level but SCJ is
proximally located. In the third type, the distal margin of the
palisade zone and SCJ coincides but the diaphragmatic indentation
is found distal in relation to them. In the fourth type, SCJ is situated
proximal to both the distal margin of the palisade zone and the
diaphragmatic indentation. Since the distal margin of the palisade
zone is known to Correspond to the GEJ, 37,40,41 the third and
fourth types can be thought to meet the definition of a hiatal hernia
(Fig. 2). However, the palisade zone may not be visible in the
presence of inflammation of the squamous epithelium that overlies
the vasculature. In normal subjects, the SCJ, the upper margin of the
gastric fold and the distal margin of the palisade zone coincide and
approximate Generally the GEJ. Therefore, either of Reviews These
markers would be suitable for diagnosing a hiatal hernia
endoscopically, but in the presence of columnar-lined esophagus
and / or Barrett's esophagus, the distal margin of the palisade zone
would be more Appropriate Whenever it can be identified. There
are many limitations in using endoscopes to diagnose a hiatal hernia.
Measuring the size of hiatal hernia with incisors as the reference
point and using centimeter markings on the scope that is spaced
every 5 cm as a ruler can be said to lack in precision. The
mouthpiece or bite block hinders viewing Also the location of the
incisor if it is not transparent. Since the esophageal hiatus is
elliptically shaped and obliquely located, the distance from the tip
of the scope to incisor would vary along the circumference of the
opening. Although we usually look for the presence and Evaluate
the extents of hiatal hernia during insertion of the endoscopes with
minimum insufflations of water, there are still confusions as to when
(during insertion or removal of the endoscopes) or at the which
phase of respiration measurements should be made, or how much
water should be insufflated. To make matters worse to, retching or
belching of the Patients during examination can alter the location
and anatomy of GEJ. Furthermore, even when the measurements are
made, there can be a great degree of inter- and intra-observer
variation among endoscopists, Thus lacking in reproducibility.43
Due to Reviews These limitations,
 2. Pathways:

Predisposition to increase intra- Predisposing congenital weakness Predisposition increasing age

abdominal pressure

Action increase LES pressure Defects weakness in the diaphragm Muscle weakness and loss of
hiatus diaphragmatic hiatus elastsitas

Cardia sphincter becomes wide

open so as to allow part of the
stomach into the thorax
Difficulty swallowing,
surgical interventions
regurgitation, dysphagia,
fundoflikasi
hiatal hernia
gastroesophageal reflux
Nausea, vomiting and
anoreksisia Antireflux barrier does not happen,
Inadequate nutrient intake postoperatively
decreased LES pressure and decreased
by esophageal acid clearance
Risk of nutritional surgical procedures
imbalance is less of a need postoperative wound
Esophageal mucosa becomes more
frequent contact with stomach fluids

Local nerve esophagitis preoperative

inflammation response
psychological response
Retrosternal pain
Port de entree risk of injury
Heartburn
Anxiety fulfillment
The risk of
information
painful
infection

(NANDA NIC-NOC, 2012;

Syamsuhidayat, 2011)
3. Nursing diagnoses
The presence of a hiatal hernia per se is not an indication for
treatment, and therapy should be given to Reviews those with
symptoms attributable to this condition. Since GERD is the most
common clinical manifestation in Patients with hiatal hernia, lifestyle
modifications (weight loss, elevation of head of bed, etc.) should be
encouraged and medications (antacids, prokinetics, H2- receptor
antagonists and proton pump inhibitors) should first be prescribed to
the symptomatic Patients, with acid suppression using proton pump
inhibitors being the cornerstone of therapy.81,82 Unlike
paraesophageal hiatal hernias that need surgical repair even in the
absence of symptoms due to its potential for development of
complications such as bleeding, incarceration , obstruction and
perforation, 83-85 isolated itself sliding hiatal hernias usually do not
require surgical treatment. However, surgical therapy (either open or
laparoscopic) could be given to a hiatal hernia Patients with severe and
refractory GERD symptoms based on the Generally Accepted
indications for antireflux surgery: poor compliance to long-term
medical therapy, the requirement of high doses of drugs and young
Patients wishing to avoid a lifetime of medical treatment.86 In addition,
hiatal hernia Patients can also resort to surgery if they develop
complications such as recurrent bleeding, ulcerations, strictures, etc.
Surgical management should encompass both the correction of hiatal
hernia by restoring the intra-abdominal esophagus and Reconstructing
the diaphragmatic hiatus, and reinforcement of the LES by Nissen
fundoplication antireflux procedure with being the most frequently
employed measure. Although endoscopic Several techniques have been
Introduced to manage GERD, Reviews These techniques are unlikely
to be effective in Reviews those with hiatal hernia since the underlying
anatomic abnormality can not be corrected.
1. Incompetence of the gastroesophageal junction
As Mentioned above, GEJ is an anatomically complex area
consisting of the intrinsic LES, the crural diaphragm, the intra-
abdominal location of the LES, the acute angle of His and the
phrenoesophageal ligaments / membrane. Among These
components, the intrinsic LES and the crural diaphragm are the two
major components of the "two-sphincter hypothesis" in the which
both the LES (smooth muscle) and the crural diaphragm (striated
muscle) are Considered to serve as sphincters.8- 10 Under normal
circumstances, Reviews These two sphincters are superimposed,
and the tonically contracted LES and the extrinsic compression by
the diaphragm create a resting LES pressure of 10 to 45 mm Hg, the
which is Sufficiently higher than the naturally occurring positive
pressure gradient of about 5 mm Hg across the GEJ to Prevent reflux
of gastric contents into the esophagus. The contribution of the crural
diaphragm in increasing the LES pressure can be appreciated in
many instances. During manometry, there is a rhythmic increase is
in the resting LES pressure of about 5 to 10 mm Hg with its pressure
being highest at the end of inspiration and Lowest at the end of
expiration. The LES pressure Also has been shown to augment in
direct proportion to the depth of inspiration, Often reaching 50 to
150 mm Hg with deep inspiration.9 Reviews These increases in the
LES pressure are largely attributable to the contraction of the
diaphragmatic crus. The role of crural diaphragm in increasing the
LES pressure Becomes particularly subject to more pronounced
during periods of elevated intra-abdominal pressures such as
coughing, abdominal straining and abdominal compression.68,69
However in hiatal hernia, the LES is displaced proximally, and this
leads to spatial separation of the intrinsic LES from the extrinsic
compression by the diaphragm, the which results in Decreased
resting LES pressure in proportion to the size of the hiatal
hernia.6,68,70 The proximal displacement of the LES in hiatal
hernia further compromises the competence of the GEJ due to the
loss of the intra-abdominal segment of the LES, Because the intra-
abdominal location of the LES per se is Considered to serve as a
valve by being exposed to the positive abdominal pressure.71,72
loss of the acute angle of His in hiatal hernia iS ALSO thought to
 add to the incompetence of GEJ possibly due to the compromise of
the flap valve effect of the structure. Due to the laxity of the
ligaments phrenoesophageal / membrane and widening of the
esophageal hiatus,
2. Relationship with transient lower esophageal sphincter relaxations
In addition to the aforementioned factors related to the
incompetence of GEJ, hiatal hernia Also seems to be associated to
some degree with tLESRs. In brief, tLESR is a phenomenon
mediated via vagal pathways that Occurs in response to distended
gastric cavity, especially the fundus, by food or gas.14 It is well
known that tLESRs are differentiated from swallow-induced LES
relaxations in Several ways: tLESRs occur Independently of
swallowing, are Unaccompanied by esophageal peristalsis, persist
for longer duration (> 10 seconds) than swallow-induced LES
relaxations, are accompanied by inhibition of the crural diaphragm
and are associated with distal esophageal shortening by the
contraction of its longitudinal muscle.14, 73.74 tLESR is a normal
occurrence during digestion and a physiological mechanism of
belching.
3. Compromise of esophageal acid clearance
In addition to the Increase in the frequency of reflux and volume of
refluxate, there IS ALSO A delay in esophageal acid clearance
among Reviews those with a hiatal hernia, 77,78 the which all
promote the increase is in esophageal acid exposure.79 in Patients
with hiatal hernia, a hernia sac (or phrenic ampulla) that is formed
by the upper margin of the LES and the diaphragmatic indentation
is present. After an episode of reflux, the refluxate is cleared from
the esophagus by secondary esophageal peristalsis into the stomach
but a small amount of acid gets entrapped in this sac. Subsequently,
the retained fluid regurgitates into the esophagus during swallow-
induced LES relaxation. Since this sequence can be repeated, it can
markedly prolong esophageal acid clearance. This finding has been
demonstrated and supported by Several studies. According to a
study that employed a simultaneous esophageal pH recordings and
 radionuclide studies after instilling acid into the esophagus, it was
demonstrated that each swallow resulted in the clearance of acid
with restoration to normal esophageal pH in subjects without a hiatal
hernia. However, subjects with hiatal hernia Showed a biphasic
response: initial swallow-induced acid reflux Followed by an initial
clearance with resultant drop in pH Followed by restoration of pH
towards normal, consistent with the aforementioned sequence.77 In
another study using concurrent videofluoroscopy and manometry,
complete esophageal emptying without retrograde flow was seen in
86% of test swallows in normal subjects (maximal length phrenic
ampullary it was demonstrated that each swallow resulted in the
clearance of acid with restoration to normal esophageal pH in
subjects without a hiatal hernia. However, subjects with hiatal
hernia Showed a biphasic response: initial swallow-induced acid
reflux Followed by an initial clearance with resultant drop in pH
Followed by restoration of pH towards normal, consistent with the
aforementioned sequence.77 In another study using concurrent
videofluoroscopy and manometry, complete esophageal emptying
without retrograde flow was seen in 86% of test swallows in normal
subjects (maximal length phrenic ampullary it was demonstrated
that each swallow resulted in the clearance of acid with restoration
to normal esophageal pH in subjects without a hiatal hernia.
However, subjects with hiatal hernia Showed a biphasic response:
initial swallow-induced acid reflux Followed by an initial clearance
with resultant drop in pH Followed by restoration of pH towards
normal, consistent with the aforementioned sequence.77 In another
study using concurrent videofluoroscopy and manometry, complete
esophageal emptying without retrograde flow was seen in 86% of
test swallows in normal subjects (maximal length phrenic ampullary
4. treatment
The presence of a hiatal hernia per se is not an indication for treatment,
and therapy should be given to Reviews those with symptoms
attributable to this condition. Since GERD is the most common clinical
manifestation in Patients with hiatal hernia, lifestyle modifications
(weight loss, elevation of head of bed, etc.) should be encouraged and
medications (antacids, prokinetics, H2- receptor antagonists and proton
pump inhibitors) should first be prescribed to the symptomatic Patients,
with acid suppression using proton pump inhibitors being the
cornerstone of therapy.81,82 Unlike paraesophageal hiatal hernias that
need surgical repair even in the absence of symptoms due to its
potential for development of complications such as bleeding,
incarceration , obstruction and perforation, 83-85 isolated itself sliding
hiatal hernias usually do not require surgical treatment. However,
surgical therapy (either open or laparoscopic) could be given to a hiatal
hernia Patients with severe and refractory GERD symptoms based on
the Generally Accepted indications for antireflux surgery: poor
compliance to long-term medical therapy, the requirement of high
doses of drugs and young Patients wishing to avoid a lifetime of
medical treatment.86 In addition, hiatal hernia Patients can also resort
to surgery if they develop complications such as recurrent bleeding,
ulcerations, strictures, etc. Surgical management should encompass
both the correction of hiatal hernia by restoring the intra-abdominal
esophagus and Reconstructing the diaphragmatic hiatus, and
reinforcement of the LES by Nissen fundoplication antireflux
procedure with being the most frequently employed measure. Although
endoscopic Several techniques have been Introduced to manage GERD,
Reviews These techniques are unlikely to be effective in Reviews those
with hiatal hernia since the underlying anatomic abnormality can not
be corrected.
 Oesopagus Gastric Duodenouscopy

Patient Education and Consent

Obtaining informed consent before esophagogastroduodenoscopy (EGD) is
extremely important and is the responsibility of the endoscopist Explain the
indications, nature, and relevant details of the procedure to the patient. Risks,
benefits, alternatives, and complications should also be presented to the patient.
The consent form should be signed and dated by the patient and endoscopist and
must be witnessed by other personnel and placed in the patient record.

Preprocedural Planning
Obtain a complete history and perform a physical examination to determine
whether EGD is appropriate. Document findings in the patient's medical record.
Direct special attention to certain illnesses that might bear a direct effect on
endoscopy, such as cardiovascular and pulmonary diseases. Obtain a history of
drug allergies and previous abdominal surgeries.
Preprocedural testing in selected cases might include, but is not limited to, a
complete blood count (CBC), blood crossmatching, coagulation studies, a
chemistry panel, urinalysis, pregnancy testing, electrocardiography (ECG), and
chest radiography. No data support routine laboratory testing prior to elective
outpatient endoscopy. Preprocedural tests should be individualized and based on
information obtained from the patient's history and physical examination and the
indication for the procedure.
Equipment
Endoscopes are available from several different manufacturers (eg, Olympus,
Pentax, and Fujinon). The conventional endoscope consists of an umbilical cord, a
control head (with wheels for up/down and left/right, an air/water button, and a
suction button), an insertion tube 100 cm in length and 8-11 mm in external
diameter, and a bending section at the tip (which allows up to 180° deflection for
retroflexion of the endoscope).
The endoscope contains a lumen for insufflation of air and water, a working channel
2-3 mm in diameter (or larger, for therapeutic endoscopes) used for suctioning and
passage of instruments, control wires for moving the tip of the endoscope, and an
imaging system that is either fiberoptic (rare) or video (widely available). The
endoscope, light source, and image source (either a video monitor or a direct view
through the eyepiece) are essential equipment. Images and video can be recorded
and printed, depending on the equipment used.
Flexible ultrathin fiberoptic and video endoscopes that can be used without sedation
are also available for EGD. These endoscopes are inserted transnasally or perorally
and have a working length of 925-1050 mm, an external diameter of 5.3-6 mm, and
a working channel diameter of 2 mm.
Multiple instruments can be introduced through the working channel of the
endoscope, including biopsy forceps, snares, sclerotherapy needles, heater probes,
electrocautery probes, balloon-dilation devices, nets, and baskets. Guide wires can
be placed, and when the endoscope is withdrawn, wire-guided bougie dilators can
be passed. Devices can also be placed onto the end of the endoscope for banding of
esophageal varices and endoscopic mucosal resection (EMR).
Some of the newer endoscopes provide high resolution and magnifying endoscopy
and are used for the evaluation of certain upper GI diseases. The upper
gastrointestinal (GI) endoscope is also used to guide endoscopic treatment of
gastroesophageal reflux disease (GERD), [18] as with the Bard EndoCinch
endoscopic suturing device and the NDO full-thickness plicator.
A potentially useful advance in video endoscopy is narrow-band imaging
(NBI). [19, 20, 21] NBI uses optical filters and high relative intensity of blue light for
imaging and characterization of mucosal morphology, such as mucosal and
superficial vascular patterns. NBI has been studied in patients with Barrett
esophagus, early gastric tumors, and colorectal lesions and has had promising
results.

Endoscopy Tower / Rack

Endoscopy Cameras

Endoscopy Light Sources

Endoscopy Video Processors

Insufflators

Gastroscopes

Colonoscopes
 Medical Scopes

Endoscope Storage Cabinets

Electrosurgical Units

Patient Preparation
Anesthesia
Conscious sedation and topical anesthesia are commonly used for EGD. The use of
monitored anesthesia care and propofol is gaining wide acceptance because of the
short recovery time. However, in many other countries, EGD is performed with
topical anesthesia only.
Topical anesthesia (eg, with Cetacaine [Cetylite Industries, Pennsauken, NJ] or
lidocaine) has the advantages of requiring less time for the overall procedure,
eliminating the risk of sedation, and decreasing the cost of the procedure by
reducing or eliminating recovery time and nursing staff. [24] The disadvantages are
patient discomfort and problems in performing the procedure on a patient who may
not be still.
With the cost-saving trends in medicine, EGD without sedation will likely become
more commonplace in the United States. With the introduction of smaller-caliber
endoscopes that can be passed through the nose, EGD without sedation may be
more acceptable to patients.
When conscious sedation is being administered, the patient must be monitored
throughout the procedure. Pulse oximetry, heart rate, and blood pressure are
commonly monitored. [25]
ECG monitoring is recommended in patients with cardiopulmonary disease, in
elderly patients, and during a prolonged procedure.
Agents that may be used in EGD include the following:
 Benzodiazepines - Midazolam, diazepam
 Opioids - Meperidine, fentanyl
 Reversal agents - Flumazenil, naloxone
Midazolam is a sedative/hypnotic commonly used for sedation in endoscopic
procedures. The peak effect of midazolam is 3-5 minutes, with a duration of action
of 1-3 hours. Some of the major adverse effects include respiratory depression,
hypotension, and paradoxical agitation. The typical starting dose is 0.5-2 mg
intravenously (IV), which can be titrated to achieve a desirable level of sedation
(usually in 1-mg increments). Lower doses of midazolam should be administered
to elderly patients with cardiopulmonary problems to avoid serious complications.
Diazepam may be used instead of midazolam for sedation during endoscopic
procedures, but many centers prefer midazolam to diazepam because of its amnestic
effect and reduced tendency to cause phlebitis.
Meperidine is a narcotic analgesic that has mild sedative properties, slow onset of
action, long duration, and long recovery time. When coadministered with
benzodiazepines, potential complications include respiratory depression and
sedation. The peak effect of meperidine is approximately 10 minutes, with a
duration of action of 2-3 hours. Adverse effects include respiratory depression,
hypotension, nausea, and vomiting. The typical starting dose is 15-50 mg IV, with
subsequent individual doses not to exceed 25 mg.
Fentanyl is a mildly sedative narcotic analgesic that has a rapid onset of action and
short recovery time. In many endoscopy centers, fentanyl is the preferred agent for
outpatient endoscopic procedures. The peak effect is 5-8 minutes, and the duration
of action is 1-3 hours. One of the major adverse effects is respiratory depression.
The typical starting dose is 0.03-0.1 mg IV, with subsequent doses of 0.02-0.05 mg.
Flumazenil is typically used for reversal of benzodiazepine-induced sedation and
respiratory depression. Flumazenil has a peak effect of 3-5 minutes and a duration
of action of 1-2 hours. Potential adverse effects include resedation and seizures.
The typical dose is 0.2-0.5 mg IV for reversal of sedation (up to 1 mg total) and 1-
3 mg IV for benzodiazepine overdose.
Naloxone reverses opioid-induced analgesia, central nervous system (CNS) effects,
and respiratory depression. Naloxone has a peak effect of 1-2 minutes and a
duration of action of 1-3 hours. Adverse effects include pain, agitation, nausea,
vomiting, arrhythmias, sudden death, pulmonary edema, and withdrawal syndrome
in patients with opioid abuse. The typical dose is 0.04 mg IV for reversal of
analgesia/sedation and 0.4 mg for narcotic overdose and respiratory arrest.
Other agents that have been tried include propofol and dexmedetomidine. In a study
comparing propofol with dexmedetomidine in patients undergoing EGD under
conscious sedation, Wu et al found that both agents offered a relatively satisfactory
level of sedation without causing clinically notable adverse effects. [26] Propofol
was preferred by patients because of the deeper sedation and rapid recovery, and
dexmedetomidine had minimal adverse effects on respiratory function.

Positioning
The patient is usually placed in the left lateral position for this procedure.
Monitoring & Follow-up
After completion of a procedure performed with the patient under conscious
sedation, transfer the patient to a recovery room for further monitoring by an
endoscopy nurse.
Once the patient is alert and mobile (after ~1 hour), the patient may be allowed to
leave the recovery room with an escort. Give the patient postprocedural instructions
(eg, regarding diet and activity), and advise him or her to watch for signs and
symptoms of GI bleeding, fever, and abdominal pain.
A follow-up appointment with the primary care physician and/or the endoscopist is
usually arranged before the patient's discharge from the endoscopy unit.

Upper Gastrointestinal Endoscopy

Antibiotic prophylaxis
Transient bacteremia may occur during most endoscopic procedures, but the risk
of infectious complications (including endocarditis) is low.
Antibiotic prophylaxis is clearly recommended when patients with an underlying
high-risk condition for infectious complications (eg, a prosthetic heart valve or a
history of endocarditis) undergo a high-risk endoscopic procedure (eg, stricture
dilation, sclerotherapy of varices, or endoscopic retrograde
cholangiopancreatography [ERCP]) in the presence of an obstructed biliary tree.
All patients undergoing percutaneous endoscopic gastrostomy (PEG)
placement should receive antibiotic prophylaxis against soft-tissue infections; the
regimen usually includes cefazolin 1 g intravenously (IV).
The patient's condition and the nature of the procedure should be reviewed
carefully, and the decision to administer antibiotic prophylaxis should be
individualized. An acceptable prophylaxis regimen is parenteral ampicillin at 2 g
and gentamicin at 1.5 mg/kg (up to 80 mg) 30 minutes prior to the procedure.
Vancomycin 1 g IV is substituted for penicillin in patients who are allergic to
penicillin.
Specific recommendations for antibiotic prophylaxis based on the type of the
endoscopic procedure that is being contemplated and the underlying patient
condition are available from the American Society for Gastrointestinal
Endoscopy (ASGE).
Procedure
The patient is usually placed in the left lateral position. Administer topical and/or
IV sedation to minimize gagging and to facilitate the procedure. An antispasmodic
agent (eg, hyoscine butylbromide, atropine, glucagon, cimetropium bromide, or
phloroglucin) may be given to suppress gastrointestinal (GI) peristalsis. Place a bite
block to prevent damage to the endoscope and to ease its passage through the
mouth.
Under direct vision, pass the endoscope through the pharynx, esophagus, and
stomach and into the duodenum, with careful inspection upon both insertion and
slow withdrawal. Insufflate air to distend the lumen so as to facilitate viewing.
Liquid and particulate matter can be aspirated through the suction channel.
 NURSING GIA Responsibility

Pre Prosedure
1. Patient arrived at endoscopy unit around 08:30Am from mulu ward and was
placed at the waiting bay/recovery bay and being monitor by the endoscopy
staff that being assign in that location
2. Assesment/interview session being done by the gastroenteriologist assistant
according the policy assessment patien in endoscopy. Arrival at the
recovery bay , observation had been done.

Day Surgery/procedur checklist

Correct patien identification : Yes
Nil oraly since : Yes
Denture Removed : Yes
Contaclens Removed : Yes
IV Canulation : No
IV Solution : No
Bledder Emptied : Yes
Bowl Preparation : No
Signed by doctor : Yes
Signed by patient : Yes
Allergy : No
BP : 110/70 mmHg
HR : 60 x/minute
RR : 20 x/minute
Temp : 36℃
Ht : 163 cm
Wt : 81 Kg
Intra Procedures
1. Patient were get in to the OGDS room
2. Topical Anesthesia lignocaine spray 10% was given. A double spray at each
left. Right and middle tonsil region. Once she feel numbness in her throat,
she were instructed to turn his body to left lateral, mouth piece insertion
and oxygen 2 liter via nasal prong was given.
3. Endoscopies then ordered to give Iv Dormicum 3mg

Report :
1. Oesophagus : Normal Mucosa, no oesophagitis, moderate hiatus hernia, no
mass lesion seen. Z-line at 38 cm from incisor
2. Stomach : nodural and body mucosa, superfacial ulcer antrum, no mass
lesion seen.
Biopsies x2 for urine positive
3. Duodenum : Nodular Mucosa D1, normal, D2, no ulcer or peri-ampularry
mass seen.

Post Procedures
Keep the patien on his side until fully awake and able to control secretion.
NO Diagnosis and data PURPOSE / CRITERIA Nursing care plan

Disorders of comfort: Disorders of comfort can - Assess quality, incidence,

1. abdominal pain associated be overcome: location and duration of pain.
with increased pressure in
the chest cavity due to Criteria: - Avoid bending forward,
temporary / permanent coughing, straining, tight clothing
displacement of the - Reduced / lost. and lifting heavy loads.
stomach, esophagus into the - The patient can rest in
thoracic cavity (chest peace. - Reduce intake of fat, alcohol,
cavity). chocolate and cigarettes.

Supporting data : - Eat small portions often.

- RR 20 x minute.
- The patient complains of - Avoid foods that are too hot / cold
abdominal pain. which can add pain.
- The patient is restless,
vomiting. - Teach effective ways to reduce
stress (relaxation techniques).

- Encourage the patient not to lie

down for 3-4 hours after eating and
raise the bed 8-10 inch to sleep
(elevation head position).

- Reduce weight if obese.

- Collaboration with the health
team:
• Administration of encouraged
and medications (antacids,
prokinetics, H2- receptor
antagonists and proton pump
inhibitors)
 Lack of knowledge about: Patient's knowledge - Assess the level of knowledge /
disease processes, about the disease process, things that are not understood by
complications and medical complications and patients.
2. procedures associated with medical measures
lack of information. increases. - Explain the patient's diet program
and provide education about
Supporting data : Criteria: nutritional status.
- Patient states do not - Patients / families are
understand about the able to mention simply - Explain the causes of reflux.
disease. what has been explained
- The patient asks for every - The patient doesn't ask - Explain the process of chronic
action to be taken. anymore. disease and tell the reason for
- Patients are less - Cooperative patients in medical therapy.
cooperative in tre the treatment program.
- Encourage the patient / family to
observe / report signs and
symptoms of possible worsening
of conditions and complications
(more painful hematemesis,
difficulty swallowing).

- Give the patient a chance to ask

questions that he has not yet
understood
 REFERENCES

Generous, D. & Rahayuningsih, T. 2010. Medical Surgical Nursing (Digestive

System). Yogyakarta: Goshen Publishing
Erickson, Kimberly Mc. Crudden. 2009. Abdominal Hernias. eMedicine Specialties.
General Surgery Abdomen.
Grace, P & Borley, N., R .2007. Surgery At Glance.Third Edition. Interpretation:
Dr. Vidhia Umami. Jakarta: publisher
Herdman, T. Heather. 2012. NANDA Nursing Diagnosis Definition and
Classification. Interpretation: Made S, & Nike B., S. Jakarta: EGC
Kluwer, Wolter., Williams, L. & Wilkins. 2012. Capita Selecta disease. Jakarta:
EGC
Lusianah & Suratun. 2010. Nursing Clients Gastrointestinal.Jakarta System
Disorders: Trans Media Info
Mansjoer, A, Kuspuji T, Rahmi S, Rev. I. W, S. 2009. Capita Selecta Wiwiek
Medicine. Jakarta: Media Aesculapius
Nurarif, A. & Kusuma, H. 2013. Based Nursing Care Medical Diagnosis &
NANDA.Jakarta: Media Action Publishing
Patrick Davey. At a Glance Medicine. 2006. Jakarta: Erland
Peter J. Kahrilas, MD,Kim Hyon C., MD, andJohn E Pandolfino, MD, 2008.
Approaches to the Diagnosis and grading of Hiatal Hernia
http://emedicine.medscape.com/article/178393-overview#showall
Downloaded May 16, 2016
Sjamsuhidajat R & de Jong, W. 2011.Asuhan Nursing Clients
Gastrointestinal.Jakarta System Disorders: Trans Media Info
Stead, Dr P. 2009. Laparascopic Hernia Repair. Issue 2. New York: Global Digital
Services & Endosurgery Institute
Sugeng, Jitowiyono and Weni Kristiyanasari. 2010. Nursing Post Operation.
Yogyakarta: Nuha Medika

Czito BG, Palta M & Willett CG. Stomach cancer. Halperin EC, Wazer DE, Perez
CA et al. (2013). Perez and Brady's Principles and Practice of Radiation
Oncology. (6th Edition). Philadelphia, PA: Lippincott Williams & Wilkins. 58.
Martini FH, Timmons MJ, Tallitsch RB. (2012). Human Anatomy. (7th Edition).
San Francisco: Pearson Benjamin Cummings.

National Cancer Institute. (2009, October 15). What You Need to Know About
Stomach Cancer. Bethesda, MD: National Cancer Institute.

Young B, O'Dowd G, Woodford P (eds.). (2014). Wheaters's Functional

Histology. (6th Edition). Churchill Livingston.