Disorder of mouth and

esophagus
GASTRO-OESOPHAGEAL REFLUX
(GERD)
PREPARED BY :NURSING INSTRUCTOR
SAIMA KOUSER

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 DEFINITION
• Gastro esophageal reflux disease (GERD)
is a chronic digestive disease. GERD
occurs when stomach acid or,
occasionally, stomach content, flows back
into your food pipe (esophagus). The
backwash (reflux) irritates the lining of
your esophagus and causes GERD.

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 WHY DOES IT OCCURS
• The lower esophageal sphincter (LES) is a
tight muscle at the bottom of the
esophagus
• The LES is designed to relax when the
food passes through the esophagus into
the stomach
• Reflux can occur when the tightness of
the LES decreases

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 CAUSES OF LES RELAXATION
• High fat and carbohydrates in diet
• Alcohol consumption
• Tobacco products
• Carminatives (peppermint & spearmint)
• Acidic fruit juices & tomato-based foods
• Some medications (e.g. calcium channel
blockers & nitrates)
• Forceful abdominal breathing

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STOMACH RELATED CAUSES
• Stomach abnormalities. One common
cause of acid reflux disease is a stomach
abnormality called a hiatus hernia, which
can occur in people of any age. A hiatus
hernia happens when the upper part of
the stomach and LES move above the
diaphragm. This is the muscle wall
separating your stomach from your chest

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HIATAL HERNIA

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 OTHER CAUSES
Eating large meals or lying down right after a meal
Being overweight or obese
Eating a heavy meal and lying on your back or
bending over at the waist
Snacking close to bedtime
Being pregnant
Taking aspirin, ibuprofen, certain muscle relaxers,
or blood pressure medications

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 Clinical Features
• Hoarseness
• Post-nasal drip
• Throat pain
• Persistent cough
• Throat clearing
• Dysphagia
• Globus sensation
• Primary symptom is heart bur

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 Cont…

Heartburn: a burning pain or discomfort that may

move from your stomach to your abdomen or
chest, or even up into your throat.

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DIAGNOSTIC TESTS

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 MEDICAL MANAGEMENT
1.Antacids that neutralize stomach acid.
Antacids, such as Mylanta, Rolaids and
Tums, may provide quick relief. But
antacids alone won't heal an inflamed
esophagus damaged by stomach acid.
Overuse of some antacids can cause side
effects, such as diarrhea or sometimes
kidney problems.

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 CONT…
2.Medications to reduce acid production. These
medications — known as H-2-receptor blockers
include:
• Cimetidine (Tagamet HB),
• Famotidine (Pepcid AC),
• Nizatidine (Axid AR)
• Ranitidine (Zantac).
• H-2-receptor blockers don't act as quickly as
antacids, but they provide longer relief and may
decrease acid production from the stomach for up
to 12 hours.

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 CONT…
3.Medications that block acid production and
heal the esophagus.
These medications — known as proton pump
inhibitors — are stronger acid blockers than H-
2-receptor blockers and allow time for
damaged esophageal tissue to heal. Over-the-
counter proton pump inhibitors include
lansoprazole (Prevacid 24 HR) and omeprazole
(Prilosec OTC, Zegerid OTC).

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 SURGICAL MANAGEMENT
• Surgery and other procedures
• GERD can usually be controlled with medication. But
if medications don't help or you wish to avoid long-
term medication use,
• Fundoplication. The surgeon wraps the top of your
stomach around the lower esophageal sphincter, to
tighten the muscle and prevent reflux. Fundoplication
is usually done with a minimally invasive
(laparoscopic) procedure. The wrapping of the top
part of the stomach can be partial or complete.

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 Cont….
• LINX device. A ring of tiny magnetic beads
is wrapped around the junction of the
stomach and esophagus. The magnetic
attraction between the beads is strong
enough to keep the junction closed to
refluxing acid, but weak enough to allow
food to pass through. The Linx device can
be implanted using minimally invasive
surgery

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NURSING MANAGEMENT OF GERD
• Accurately measure the patient’s weight
and height. For baseline data.
• Obtain a nutritional history. Determining
the feeding habits of the client can provide
a basis for establishing a nutritional plan.
Encourage small frequent meals of high
calories and high protein foods. Small and
frequent meals are easier to digest.

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 CONT…
• Instruct to remain in upright position at
least 2 hours after meals; avoiding eating
3 hours before bedtime. Helps control
reflux and causes less irritation from
reflux action into esophagus. Instruct
patient to eat slowly and masticate foods
well.

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 Cont….
• Maintain vitals signs .
• Provision of medicine by following
medication rules.
• Assess the patient for recovery.
• Provide pre & post surgery care to patient
if surgery is suggested.

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 Complications of GERD
• Esophagitis (inflammation of the
esophagus)Esophageal bleeding, or an
ulcer from chronic or severe Esophagitis.
• Esophageal scarring, which can cause your
esophagus to narrow and make
swallowing harder.
• Tooth decay.
• Sleep apnea

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HIATAL HERNIA

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 DEFINITION

A hiatal hernia occurs when a portion of

the stomach prolapse through the
diaphragmatic esophageal hiatus. Most
hiatal hernias are asymptomatic and are
discovered incidentally, but rarely, a life-
threatening complication may present
acutely. The image below depicts a para-
esophageal hiatal hernia.

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CLASSIFICATION

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Cont….

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 CAUSES
• Age-related changes in your diaphragm
• Injury to the area, for example, after
trauma or certain types of surgery
• Being born with an unusually large hiatus
• Persistent and intense pressure on the
surrounding muscles, such as while
coughing, vomiting, straining during a
bowel movement, exercising or lifting
heavy objects

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 CLINICAL FEATURES
• Heartburn
• Regurgitation of food or liquids into the mouth
• Backflow of stomach acid into the esophagus
(acid reflux)
• Difficulty swallowing
• Chest or abdominal pain
• Shortness of breath
• Vomiting of blood or passing of black stools,
which may indicate gastrointestinal bleeding

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 DIAGNOSIS

• X-ray of your upper digestive system.

• Upper endoscopy
• Esophageal manometry.
• A pH test can also measure the acid
levels in the esophagus.

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Life Style and Diet Changes for Hiatal Hernia

• Lifestyle changes are often necessary to avoid

symptoms of hiatal hernia.
• Modify your activities:
– Minimize heavy lifting, straining, bending over.
– Improve seated posture; don't slouch.
– Exercise more.
– Lose weight.
– Sleep on an incline, with head of bed raised 4-6 inches
on blocks.
– Choose standing activities after a meal rather than
sitting or reclining

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 Modify your diet.
• Avoid the following:
• Caffeine
• Chocolate
• Fried or fatty foods
• Peppermint
• Alcohol
• Meals within 2-3 hours of bedtime
• Large meals (eat smaller meals more
frequently

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 MEDICAL TREATMENT
• Hiatal hernia medications.
• Proton pump inhibitor medications are
commonly used to decrease acid
production.
• These include omeprazole (Prilosec),
lansoprazole (Prevacid), pantoprazole
(Protonix), rabeprazole (Aciphex) and
esomeprazole (Nexium).

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 SURGICAL MANAGEMENT
The most common procedure of this type
is called fundoplication. In this surgery,
your surgeon will: First repair the hiatal
hernia, if one is present. This involves
tightening the opening in your diaphragm
with stitches to keep your stomach from
bulging upward through the opening in
the muscle wall.

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ACHALASIA

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 DEFINITION
• Achalasia is a serious condition that
affects your esophagus. The lower
esophageal sphincter (LES) is a muscular
ring that closes off the esophagus from
the stomach. If you have achalasia, your
LES fails to open up during swallowing,
which it's supposed to do. This leads to a
backup of food within your esophagus.

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 CAUSES
• Esophageal spasm is not common. ...
Achalasia is a problem with the nervous
system in which the muscles of the
esophagus and the lower esophageal
sphincter (LES) don't work properly.
Anxiety or panic attacks can also cause
similar symptoms

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 CONT…
• The degeneration of nerves .
• Cancer of the esophagus is one of these
conditions.
• Another cause is a rare parasitic
infection called Chagas' disease
• This condition may be hereditary.

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 CLINICAL FEATURES
• Pain or discomfort in your chest
• weight loss
• Intense pain or discomfort after eating
• People with achalasia will often have
trouble swallowing or feel like food is
stuck in their esophagus. This is also
known as dysphagia.

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• This symptom can cause coughing and
raise the risk of aspiration, or inhaling
or choking on food.
• Heartburn

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 How is achalasia diagnosed?
Esophageal manometry
X-ray or similar exam of your esophagus
Endoscopy.
Another diagnostic method is a
barium swallow. If you have this test,
you’ll swallow barium prepared in liquid
form. Your pathologist will track the
barium’s movement down your
esophagus through X-rays.

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 MANAGEMENT
• As a first-line therapy, dilate the sphincter
or alter it. Dilation typically involves
inserting a balloon into your esophagus
and inflating it. This stretches out the
sphincter and helps your esophagus
function better. However, sometimes
dilation tears the sphincter. If this happens,
you may need additional surgery to repair
it.

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 Medical therapy
• Oral pharmacologic therapies are the least
effective treatment options in achalasia
• Calcium channel blockers
• long-acting nitrates
• are the two most common medications
used to treat achalasia. They transiently
reduce LES pressure by smooth muscle
relaxation, facilitating esophageal emptying

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 Calcium channel blockers
• Amlodipine (Norvasc)
• Diltiazem (Cardizem, Tiazac, others)
• Felodipine.
• Isradipine.
• Nicardipine.
• Nifedipine (Adalat CC, Afeditab CR, Procardia)
• Nisoldipine (Sular)
• Verapamil (Calan, Verelan

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 Long acting nitrates

• Specific drugs used for cost range Cost

per year (£)Long-acting nitrates
• Low = isosorbide mononitrate
• High = isosorbide dinitrate

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 DIVERTICULA
• Diverticular disease is a very common
condition which occurs due to the ageing
of muscles that make up the wall of the
large bowel. Small bulges develop as the
internal layer of the bowel pushes
outwards through the weakened muscle
to form pockets called diverticulae.

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A single sac is called a diverticulum. Two or more
sacs are called diverticula.

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 CAUSES
• Diverticulitis is caused when stool and
bacteria are retained in the Diverticular
out pouches, leading to the formation of
a hardened mass called a fecalith. The
fecalith obstructs blood supply to the
Diverticular area, leading to
inflammation, edema of tissues, and
possible bowel perforation and
peritonitis.

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 CONT….
• Examples of low-fiber foods include:
• Canned or cooked fruits without skin or seeds.
• Canned or cooked vegetables such as green
beans, carrots and potatoes (without the skin)
• Eggs, fish and poultry.
• Refined white bread.
• Fruit and vegetable juice with no pulp.
• Low-fiber cereals.
• Milk, yogurt and cheese.

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 HOW TO DIAGNOSED
• History of current medications
• Perform a physical exam, possibly
including a digital rectal exam.
• Tests may include:
• X-rays, CT scanning, ultrasound testing,
sigmoidoscopy, colonoscopy, Blood
tests(to chcek the signs of infection)

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 TREATMENT
• MEDICAL MANAGEMENT:
• One typical oral antibiotic regimen is a
combination of
• Ciprofloxacin (or trimethoprim-
sulfamethoxazole) and metronidazole.
Moxifloxacin is appropriate monotherapy for
outpatient treatment of uncomplicated
diverticulitis.
• Amoxicillin monotherapy is acceptable as wel

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 NURSING MANAGEMENT
• TO ASSESS THE PATIENT FOR PAIN:
• To reduce abdominal pain caused by mild
diverticulitis:
• Apply a heating pad to your abdomen to
relieve mild cramps and pain.
• Try relaxation techniques (such as slow, deep
breathing in a quiet room or meditation) to
help reduce mild pain.
• Use a nonprescription pain medicine such as
acetaminophen (for example, Tylenol).

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 CONT…
• When administering medications,
monitor the patient for desired effects
and possible adverse reaction.
• Maintain bed rest for patient with acute
diverticulitis.
• Maintain liquid diet during the acute
attack.

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 CONT..
• Monitor the patient for signs and
symptoms of complications. Watch for
temperature elevation, increasing
abdominal pain, blood in stools, and
leukocytosis.

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 SURGICAL MANAGEMENT
• Elective surgery for uncomplicated
diverticulitis. ... On the contrary, a lower
threshold for both elective and urgent
resection has been recommended in
immunocompromised patients, given the
associated increased risk for failure of
medical management and increased risk of
recurrent disease with significant
morbidity.

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 ESOPHAGEAL CANCER
• Esophageal cancer is a disease in which
malignant (cancer) cells form in the tissues
of the esophagus. The esophagus is a
muscular tube that moves food and liquids
from the throat to the stomach. The most
common types of esophageal cancer are
squamous cell carcinoma and
adenocarcinoma.

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 CAUSES
• Factors that cause irritation in the cells of your
esophagus and increase your risk of esophageal cancer
include:
• Having gastroesophageal reflux disease (GERD)
• Smoking.
• Having precancerous changes in the cells of the
esophagus (Barrett's esophagus)
• Being obese.
• Drinking alcohol.
• Having bile reflux.

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 CLINICAL FEATURES
• Signs and symptoms of esophageal cancer
include:
• Difficulty swallowing (dysphagia)
• Weight loss without trying
• Chest pain, pressure or burning
• Worsening indigestion or heartburn
• Coughing or hoarseness

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 DIAGNOSIS
• Using a scope to examine your esophagus
(endoscopy).
• Collecting a sample of tissue for testing
(biopsy).
• Endoscopic ultrasound (EUS)
• Computerized tomography (CT)
• Positron emission tomography (PET)

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 MANAGEMENT
• SURGICAL MANAGEMENT:
• Surgery to remove the cancer can be used
alone or in combination with other treatments.
• Surgery to remove very small tumors.
• Surgery to remove a portion of the esophagus
(esophagectomy).
• Surgery to remove part of your esophagus and
the upper portion of your stomach
(esophagogastrectomy).

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 CHEMOTHERAPY

• Chemotherapy is drug treatment that

uses chemicals to kill cancer cells.
• Carboplatin and paclitaxel (Taxol®) (which
may be combined with
radiation)Cisplatin.
• 5-fluorouracil (5-FU)

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 RADIATION THERAPY
• Radiation therapy uses high-powered X-
ray beams to kill cancer cells. Radiation
typically will come from a machine
outside your body that aims the beams
at your cancer (external beam radiation).

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 NURSING MANAGEMENT
• Find out enough about esophageal cancer
to make decisions about your care.
• Provide open, nonjudgmental
environment. Use therapeutic
communication skills of Active-Listening,
acknowledgment, and so on.
• Be aware of debilitating depression. Ask
patient direct questions about state of
mind

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 CONT….
• Reinforce teaching regarding disease
process and treatments and provide
information as appropriate about dying.
Be honest; do not give false hope while
providing emotional support.
• Identify positive aspects of the situation

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 CONT…
• As patient has dysphagia so maintain
the diet and fluid intake properly.
• Supplementation is necessary as patient
losing weight continuously.
• Administer medication as prescribed.
• Pain management therapies.

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