Gastroesophageal Reflux Disease or Hiatal Hernia

1. DESCRIPTION/ DEFINITION/ CLASSIFICATION & DIFFERENTIATION

Description:
 Gastroesophageal reflux disease (GERD) occurs when stomach acid frequently
flows back into the tube connecting thr mouth and stomach (esophagus). This
backwash (acid reflux) can irritate the lining of thr esophagus.
 Hiatal hernia is a condition in which a portion of the stomach extends and
protrudes up through the diaphragm into the esophagus, trapping stomach acid
and causing it to reflux into the esophagus.
2. CONCEPT MAP or TRACING of the PATHOPHYSIOLOGY

GERD

Non-modifiable risk factors Modifiable risk factors

 Obesity  Smoking
 Bulging of the top of the  Eating large meals or eating
stomach up into the late at night
diaphragm (hiatal hernia)  Eating certain foods
 Pregnancy (triggers) such as fatty or
 Connective tissue fried foods
disorders, such as  Drinking certain beverages,
scleroderma such as alcohol or coffee
 Delayed stomach emptying  Taking certain medications,
such as aspirin

Increases the chance of frequent Nursing Interventions:

Nursing Diagnoses: backflow of stomach acid 1. Obtain a nutritional
1. Imbalanced nutrition: less history.
than body requirements 2. Encourage small
related to inability to intake frequent meals of high
enough food because of Maternal signs and symptoms calories and high
reflux. protein foods.
2. Acute pain related to  A burning sensation in your
3. Assess for heartburn
chest (heartburn), usually
gastroesophageal 4. Avoid placing patient
after eating, which might be
3. Risk for aspiration related worse at night in supine position,
to esophageal compromise have the patient sit
affecting the lower  Chest pain upright after meals.
esophageal sphincter 5. Assess patient for
 Difficulty swallowing
4. Deficient knowledge information needed
related to lack of  Regurgitation of food or and ability to perform
information regarding sour liquid actions independently.
condition/disease process.
 Sensation of a lump in your
5. Imbalanced Nutrition: More throat
Than Body Requirements
related to decreased  Chronic cough
metabolic rate
 Laryngitis

 New or worsening asthma

 Disrupted sleep
3. DIAGNOSTIC/ LABORATORY TESTS

 EGD: An esophagogastroduodenoscopy or upper endoscopy is a procedure

that allows the doctor to examine the inside of the esophagus, stomach, and
duodenum. A thin, flexible, lighted tube, called an endoscope, is guided into
the mouth and throat, then into the esophagus, stomach, and duodenum. The
endoscope allows the doctor to view the inside of this area of the body, as well
as to insert instruments through a scope for the removal of a sample of tissue
for biopsy (if necessary).

-Pre
 Introduce yourself and identify the patient.
 Explain the procedure to the patient.
 Assess the history of signs and symptoms that the patient
experienced.
 Instruct the patient that is important to have an empty stomach for this
test so the patient should not have anything to eat or drink (except
small sips of water to take any oral medications with) for at least 6
hours prior to the procedure.
 Inform the patient not to take any antacids, aspirin, or ibuprofen
(Advil, Motrin, Alleve).
 Ask to sign a consent form indicating an agreement to proceed with
the test.
 Ask the patient to put on a hospital gown and to remove any glasses,
contacts, and dentures.
 Give a combination of intravenous medications to put patient under
“conscious sedation”.
-Intra
 Ask the patient to lie on the right side.
 Spray local anesthetic (with a bitter taste) into the mouth to make it
numb and reduce gagging.
 Place monitoring devices on skin to measure blood pressure, heart
rate, and blood oxygen during the procedure.
 Place the thin flexible tube (endoscope) through the mouth guard.
Advance the scope down the esophagus.
-Post
 Inform the patient regarding the result of the physical examination.

 24 hour pH-metry: Important for patients when the diagnosis of GERD cannot
be confirmed on EGD or diagnostic uncertainty exists. A normal 24-hour
intraesophageal pH study after an H2-blocker and proton pump inhibitor (PPI)
free interval should strongly suggest an alternate diagnosis and lead to
additional diagnostic investigations. This test consists of a small tube passed
through the nose into the esophagus at the level of the LES. A pH sensor at
the tip of the tube allows measurements of acid exposure in the esophagus to
be collected on a portable computer. The pH probe is worn for 24 continuous
hours. The tube is then removed and the results from the computer are
interpreted. These results are compared to what we know is the normal acid
exposure in the esophagus. This is truly the "gold standard" for determining if
the patient has reflux disease. Generally, a pH probe is ordered if the
 physician is not sure a patient's symptoms are related to GERD or if a patient
with GERD has not responded to medical therapy.

-Pre
 Introduce yourself and identify the patient.
 Explain to the patient the procedure you are going to do.
 Instruct the patient to avoid eating and drinking 8 – 12 hrs prior to the
test.
 Instruct patient not to take any over-the-counter antacids at least 24
hours before the test.
 Instruct patient that she will be asked to keep a diary during the testing,
including every time she eats, drinks, or takes medicines, and how long
that lasts, when you she down and get up, and each and every time she
have a symptom of interest (like heartburn, regurgitation, cough, sore
throat, etc.).
 Instruct patient that she cannot take a shower or bath while wearing the
monitor. And should be careful around pets and small children to make
sure they do not come close enough to accidentally pull the catheter
out.
 Instruct patient that she should otherwise go about her daily routine and
eat her regular diet in order to get a realistic recording of how much
reflux occurs during the usual routine.
-Intra
 Place a catheter (about the size and flexibility of a smartphone power
cord) through the patient’s nasal passage, and then swallowed into the
esophagus with drinks of water.
 Tape the other end of the catheter to the patient’s cheek and wrap over
the ear, and attach to a small data recorder that the patient will wear at
waist level, held by a strap over the shoulder.
 Inform patient that she will be able to swallow, talk, and breathe without
any difficulty during the test.
-Post
 Inform patient that the doctor will receive the final results of the
procedure in about 1 week, and will communicate the results to her.

 Esophageal manometry: Frequently performed before surgery and

advocated by many experts in order to identify conditions that might
contraindicate fundoplication (such as achalasia) or modify the type of
fundoplication according to a tailored approach based on esophageal motility.
This test is used to diagnose problems involving the movement and function of
the esophagus. The procedure involves the insertion of a pressure-sensitive
tube into the nose that is then fed into the throat, esophagus, and, stomach.
Esophageal manometry is used when there is a chronic reflux or swallowing
problems that cannot be explained.

-Pre
 Introduce yourself and identify the patient.
 Explain to the patient the procedure you are going to do.
 Instruct the patient to avoid eating and drinking 4 – 6 hrs prior to the
test.
  Ask patient for drugs that she is taking that could interfere with the
motility of the esophagus (Anticholinergics, Calcium channel blockers,
Nitrates, Sedatives)
 Provide a hospital gown and ask to sit on an examination table. Ask
patient to remove glasses and anything in the mouth that could be
dislodged, such as a tongue piercing.
 Ask patient to choose of which nostril to use for the test. (The nasal
route is preferred as it is less likely to cause gagging than the throat.)
 Ask patient to relax by slowing the breathing, relaxing the shoulders,
and unclenching the fists. If the patient feels any discomfort, let the
nurse know without panicking.
-Intra
 Lubricate the catheter with the topical anesthetic before inserting.
Patient’s nostril may also be lubricated.
 As the catheter is inserted, it will reach a point of resistance as it makes
an acute angle into the throat. Ask patient to tilt head down to help ease
the catheter in.
 To move the catheter past the UES, patient will be asked to sip water
through a straw. Doing so opens the sphincter, allowing the catheter to
enter with minimal resistance.
 Once the catheter is past the UES, it is quickly fed into the esophagus
and stomach. Tape catheter in place and ask patient to lie on her side.
 The doctor then starts to calibrate the catheter sensors. At this point,
ask patient to refrain from swallowing to ensure the calibration is
correctly set.
 Testing begins when the two last sensors are correctly positioned in the
stomach. The sensor is set at zero to serve as the baseline for
comparison.
 As the catheter is withdrawn to the LES, patient is asked to take several
sips of water. Doing so allows the doctor to measure changes in the
sphincter pressure from a closed state (before swallowing) to an open
state (after swallowing).
 Ask patient to take additional sips of water to measure changes in
esophageal pressure as she swallows. If peristalsis is normal, the
doctor will see rhythmic changes in pressure moving downward.
 Finally, to test the UES, patient will be asked to sit up. The catheter is
gradually withdrawn to compare the pressure at the UES with that of the
esophagus and throat.
 The catheter is then be gently removed.
-Post

Give patient a tissue to blow her nose.

Inform patient that she can resume normal diet and any medications
she regularly take.
 Inform patient of the side effects of esophageal manometry which may
include a mild sore throat, coughing, minor nosebleeds, and sinus
irritation.
 Barium swallow: Frequently obtained test for better delineation of the
anatomy. May be particularly valuable in patients with large hiatal hernias who
have a shortened esophagus. Barium is a white liquid that is visible on X-rays.
Barium passes through the digestive system and does not cause a person any
harm. As it passes through the body, barium coats the inside of the food pipe,
stomach, or bowel, causing the outlines of the organs to appear on X-ray.

-Pre
  Ask patient to wear a hospital gown and to remove all jewelry including
body jewelry that might show up on an X-ray.
 Ask to sign a consent form indicating an agreement to proceed with the
test.
-Intra
 Ask patient to drink about 1 1/2 cups of a barium preparation-a chalky drink
with the consistency (but not the flavor) of a milk shake. The barium can be
seen on an X-ray as it passes through the digestive tract.
 The barium swallow procedure may take about 30 minutes to finish. In
certain cases, it may take up to 60 minutes to fill the stomach.
 Strap patient securely on her back on a table that tilts forward. X-rays to
examine the heart, lungs, and abdomen will be taken before patient drinks
the barium. Ask patient to swallow the barium mixture.
 Inform patient that x-rays will be taken again as the barium moves through
the digestive system. Ask patient to take more swallows so more pictures
can be taken.
 As the barium moves down thr digestive system, the table will be tilted at
various angles to help spread the barium for different views. Pressure may
be applied to the abdomen to spread the barium.
 Finally, place patient horizontally, ask to take a few more swallows of
barium, and X-ray again.

Presence of reflux is understood through patient’s history. Upper gastrointestinal

endoscopy is reliable and endoscopy is not risky in pregnancy. However,
gastroenterologists still avoid this procedure in expectant mothers as far as possible.
Endoscopy is indicated if reflux symptoms persist despite medical treatment and
lifestyle changes or if additional symptoms including hematemesis or dysphagia are
present. Manometer and pH-meter can be used safely but are seldom indicated.

4. TREATMENT REGIMEN

A. MEDICATIONS/ SUPPLEMENTS/VACCINES
 Antacids- Antacids or sucralfate should be used first. Symptomatic treatments
without systemic effect or absorption should be preferred. Antacids, which are
non-systemic drugs, should be initiated in pregnant women who do not respond to
lifestyle changes, and they should be used as the first choice in treatment. They
offer the required relief in many women with mild symptoms. Preferably, the
antacid + alginic acid combination is more beneficial. Medicinal products
containing antacid plus alginic acid act by forming a layer over the stomach
content, neutralizing the existing acid and preventing the effect of the refluxing
material on the esophageal mucosa. Long-term and high-dose Mg++ trisilicate
should be avoided, especially in the third trimester, as it may lead to contractions.
Na+ bicarbonate should be avoided since it may lead to edema and hypertension.
Those that contain aluminum may result in constipation.
 Sucralfate- As an aluminum salt that acts by inhibiting pepsin activity, sucralfate
seems to be safe since it is not absorbed from the gastrointestinal tract.
Sucralfate is taken orally as 1 g three times daily but should this proves
inadequate, it may be combined with lifestyle changes together with antacid +
alginic acid treatment. No maternal or fetal side effects associated with sucralfate
have been reported. H2 receptor antagonist: Of the H2 receptor antagonists,
ranitidine is FDA category B, while information on others is limited, and they may
possibly be safe.
 Proton pump inhibitors (PPIs)- except for omeprazole, all proton pump inhibitors
(PPIs) are classified as category B drugs by the US Food and Drug Administration
 (FDA), which means that they are safe to use during pregnancy. Omeprazole is
currently classified as a category C drug (Animal studies show risk but human
studies are inadequate or lacking or no studies in humans or animals). However,
since the category rating for omeprazole was established, multiple studies have
been published demonstrating that omeprazole is as safe as any other PPI for
pregnant women.

B. SURGERY
Several tests are necessary to determine if a person is a good candidate for antireflux
surgery. The purpose of these studies is to:

 Identify objective evidence of reflux,

 Correlate reflux with symptoms, and
 Evaluate for other coexisting diseases that may be contributing to
symptoms.

Required Tests prior to surgery:

 Upper Endoscopy – An upper endoscopy or EGD involves placing a small

camera through the mouth and into the upper gastrointestinal tract allowing
evaluation of the esophagus, stomach, and first part of the small intestine
(duodenum). This is generally done as an outpatient procedure under mild to
moderate sedation. The purpose of endoscopy is to evaluate for reflux-related
damage, to assess the integrity of the LES, and to identify any alternative or
coexisting disease processes that may be contributing to symptoms. Long-term
exposure of the esophagus to gastric acid can cause damage such as erosion
(esophageal ulcers), inflammation (esophagitis), scarring (esophageal stricture),
and changes to the inner esophageal lining (Barrett’s esophagus). During an
endoscopy, potential abnormalities such as gastritis, peptic ulcers, polyps,
nodules, and infections can also be assessed. Tissue samples (biopsies) of the
esophagus, stomach and duodenum are often obtained during this procedure.
Stomach tissue samples are often tested for an infection called H. pylori.
 24-Hour pH Test – A pH study involves a thin, soft silastic tube (catheter)
inserted through a patient’s nose and into the distal esophagus above the LES.
Sensors on the tube detect and record acid reflux episodes. The device is also
designed to record when a patient feels symptoms to determine if these
symptoms correlate with reflux episodes. This test is conducted over a 24-hour
period on an ambulatory patient who is off acid-suppression medications. During
the test the individual is able to continue routine activities. One version of this test
involves the attachment of an acid sensing chip on the lining of the lower
esophagus. This is known as a Bravo probe and has the advantage of avoiding
insertion of a tube through the patient’s nose.
 Esophageal Impedance pH Study – Many physicians are also utilizing the 24-
hour esophageal impedance study for evaluation of reflux in certain patients,
which involves the same procedure described above (a tube passed through the
nose into the esophagus). Esophageal impedance detects fluid reflux whether or
not it is acidic. Both acid and non-acid reflux events are therefore measured.
Individuals may have non-acid or weakly acid reflux, or continue to have
symptoms despite high dose acid suppression and the impedance study can
provide valuable information in these cases. (The Bravo study probe only
measures acid so cannot be used for the impedance study.)
 Manometry – Esophageal manometry measures the motor or contractile function
of the LES and the esophagus. This test is mainly used to evaluate for any
underlying esophageal motility disorders that may be contributing to a person’s
symptoms (such as achalasia).
Surgery:

 Nissen Fundoplication- This is the standard surgical treatment for GERD. It

tightens and reinforces the LES. The upper part of the stomach is wrapped
around the outside of the lower esophagus to strengthen the sphincter.
Fundoplication can be performed as an open surgery. During an open surgery,
the surgeon makes a long incision in the stomach to access the esophagus. It
can also be performed as laparoscopic surgery. This type of surgery involves
several smaller incisions. Miniaturized instruments are used to make the process
less invasive.
Preparation for surgery
 a clear liquid diet 1-2 days before surgery
 not eating on the day of surgery
 taking a medication to cleanse your bowels the day before surgery

 EsophyX Transoral Incisionless Fundoplication or EsophyX TIF- is performed

transorally (through the mouth).The procedure reduces a small hiatal hernia and
creates a one way valve between the stomach and esophagus, restoring the
natural, physiological anatomy to prevent GERD. EsophyX TIF generally takes
less than an hour, and most patients can return to work the next day or within a
few days. Because no incision is needed, there is reduced pain, shorter recovery
time and no visible scar. Patients may expect to experience some discomfort in
their chest or nose and throat for the first few days (sometimes up to a week),
and should restrict physical activity for the first week and follow dietary guidelines
while the tissue heals. Recent studies have shown that EsophyX can reduce
patients’ dependency on medications and dramatically improve quality of life; 70
percent of patients have remained symptom-free after two years, and most
patients can eat and drink foods they avoided for many years.

C. DIET OR NUTRITION
 Eat low fat diet
 Eat smaller meals more frequently and avoid drinking while eating. Drink
water in between meals instead
 Eat slowly and chew every bite thoroughly.
 Avoid eating a few hours before bed.
 Avoid foods and beverages that trigger your heartburn. Typical culprits
include chocolate, fatty foods, spicy foods, acidic foods like citrus fruits
and tomato-based items, carbonated beverages, and caffeine.
 Stay upright for at least one hour after a meal. A leisurely walk may also
encourage digestion.
 Maintain a healthy weight.
 Chew a piece of sugarless gum after meals. The increased saliva may
neutralize any acid coming back up into the esophagus.
 Eat yogurt or drink a glass of milk to quell symptoms once they start.
 Drink some honey in chamomile tea or a glass of warm milk.
D. EXERCISE
 It is advised for patients with GERD to avoid strenuous physical activities
as this trigger the occurrence of reflux.

5. PREVENTION & PROGNOSIS

Prevention:
 Eat several small meals each day instead of three large ones.
  Eat slowly.
 Avoid fried, spicy, or rich (fatty) foods or any foods that seem to cause
relaxation of the lower esophageal sphincter and increase the risk of
heartburn.
 Drink less while eating. Drinking large amounts while eating may increase
the risk of acid reflux and heartburn.
 Don't lie down directly after eating.
 Keep the head of your bed higher than the foot of your bed. Or place
pillows under your shoulders to help prevent stomach acids from rising
into your esophagus.
 Ask your doctor about using over-the-counter medications such as Tums
or Maalox, which are generally safe to use during pregnancy. You may
find that liquid heartburn relievers are more effective in treating heartburn,
because they coat the esophagus.
 Wear loose-fitting clothing. Tight-fitting clothes can increase the pressure
on your stomach and abdomen.
 Avoid constipation.

Prognosis:
 Prognosis for People with Gastroesophageal Reflux Disease In some
cases, patients with GERD are able to heal completely without further
flare-ups or complications with an effective treatment plan. Usually,
patients who seek treatment as quickly as possible have the best
prognosis.

References:
https://www.verywellhealth.com/esophageal-manometry-test-4157830