Stomatitis

1. Comprehend the definition and be enlightened about the different classifications of

stomatitis.
2. Review the causes and risk factors for developing aphthous stomatitis.
3. Enlist the signs and symptoms of patients with stomatitis.
4. Describe the typical diagnostic findings of aphthous stomatitis and characterize to
differentiate aphthous stomatitis from other causes of oral ulcerations.
5. Outline the nursing management considerations, pharmacotherapy and surgical
interventions to achieving an optimal health outcome for patients with aphthous
stomatitis.

Oral inflammation and ulcers, known as stomatitis, is a common ailment, idiopathic in nature,
with recurrent swelling and redness on the non-keratinized oral mucous membranes. Stomatitis
can affect any of the structures in the mouth: cheeks, gums, tongue, throat, lips, and roof or floor.
Less commonly, whitish lesions form and the mouth rarely appears normal despite significant
symptoms (burning mouth syndrome). Symptoms hinder eating, sometimes leading to
dehydration and malnutrition. Secondary infection occasionally occurs, especially in
immunocompromised patients.

painful aphthous ulcers (commonly termed "canker sores")

condition of the inflammation of the mouth. It greatly affects the thin skin coverings on the inner
part or surface of the mouth (mucous membranes). The said membranes produce the protective
mucus and lining the digestive system from the mouth to the anus. Moreover, Stomatitis is a type
of mucositis or the inflammation of the mucous membrane where it us considered as a common
side effect of chemotherapy and radiotherapy. It can affect the inside of the cheeks, lips, tongue,
gums, and throat.
Stomatitis that occurs once again and includes mouth ulcers is called RAS or recurrent aphthous
stomatitis that affects the mouth area. From different sources, it is said that 5 to 25 percent of the
population in the US are affected.

There are two types of Stomatitis:

• Canker Sores —also known as aphthous ulcers,
was also considered as a part of the most common cause of stomatitis. The sores in this type of
stomatitis appears to be pale white or yellowish intertwined with a red outer ring.
are small, shallow lesions that develop on the soft tissues in your mouth or at the base of your
gums. Most canker sores go away on their own in a week or two. Check with your doctor or
dentist if you have unusually large or painful canker sores or canker sores that don't seem to heal.
Aphthous Ulcers can develop in a cluster and it usually appears on the inside part of the lips or
on the tongue, or cheek. The said type continuously lead to temporary pain and some usual cases,
it heals within 4 to 14 days (14 days as the maximum). However, in the worst cases, which only
happen to 1 out of 10 people, the sores can be treated for atleast 6 weeks. Truth to be told,
anyone can get the said type of stomatitis but the people who are likely to experience this disease
are women and girl teens under 20's. Although this might be generational or it can run in the
family, the disease is not contagious.
• Cold Sores —
Unlike cold sores, canker sores don't occur on the surface of your lips and they aren't contagious.
They can be painful, however, and can make eating and talking difficult.

these are small, fluid-filled, and painful sores that appears on or around the lips near the outline
of the mouth and this is usually caused by the HSV (Herpes Virus) — another condition also
known as herpes stomatitis. A person under this condition may experience a burning or tingling
sensation just before sore appears occurs in the mouth and they mey also experience tenderness.
It dries up and crust over with a yellowish scab. It is said that cold sores usually stays for around
5-7 days and its not certain that it would permanently vanish after that because as for some
patients, cold sores keeps on coming back. And not just that, but cold sores are very contagious.
Lastly, Stomatitis can be divided into different categories that depends on which area of the
mouth is being affected:
• Cheilitis – inflammation of the lips and around the mouth
• Gingivitis — inflammation of the gums
• Glossitis – inflammation of the tongue
• Pharyngitis – inflammation of the back of the mouth

Etiology
Stomatitis may be caused by local infection, systemic disease, a physical or chemical irritant, or
an allergic reaction (see the table Some Causes of Stomatitis); many cases are idiopathic.
Because the normal flow of saliva protects the mucosa against many insults, xerostomia
predisposes the mouth to stomatitis of any cause.
explain the causes of and medications commonly associated with stomatitis. Radiotherapy to the
mouth results in substantial local oral mucosal damage in both acute and late stages. Radiation-
induced stomatitis is characterized by xerostomia (dry mouth due to lack of saliva), diffuse
erythema, ulceration, taste alteration, oral soreness, dysphagia, difficulty talking, and mouth
odour.
Causes of stomatitis
 Chemotherapy and radiation therapy
 Loose-fitting dental prosthetics
 Trauma
 Poor dental hygiene
 Tobacco smoking and irritating foods or chemicals
 Hematologic malignancies (stomatitis develops at 2 to 3 times the rate of solid tumours)
 Infection (viral, fungal, and bacterial) (Candida albicans and bacteria)
 Viral infections, , particularly herpes simplex and herpes zoster
 Dehydration
 Medications
 Alcohol
Medications associated with stomatitis
 Chemotherapy
 Antihypertensives
 Opioids
 Antibiotics (indirect)
 Diuretics (increase risk of dehydration in compromised state)
 Anticholinergics
 Antihistamines and decongestants
 Steroids
 Antidepressants

The causes of stomatitis will depend on the specific subtype. For instance, aphthous stomatitis
(Cranker Sore) and herpes stomatitis (Cold Sore) may have similarities regarding the causes but
they also have subordinating differences. For instance, cold sore is mainly caused by the herpes
simplex virus (HSV-1). On the other hand, ranker sore or aphthous stomatitis is caused by poor
oral hygiene and/or trauma to the mucous membranes.
Other causes of stomatitis also exist and this includes local infection (e.g., Candida albicans,
bacteria); nutritional deficiencies (vitamin B12 deficiency); systemic diseases (e.g., Behçet
disease, inflammatory bowel disease); chemical and/or physical irritants (e.g., oral care
products), or an allergic reaction.
However, it is important to note that many causes of stomatitis are unknown or idiopathic. But
the potential patient may consider some of these causes as to why stomatitis occurs;
chemotherapy treatment for cancer viral infection like surgery, trauma from ill-fitting dentures,
biting the inside of the cheek, tongue, or lip, smoking or chewing tobacco, bacterial infections,
weakened immune system, sexually transmitted infections, stress, certain diseases, including
Behcet’s disease, lupus medications like sulfa drugs, antibiotics, and anti-epileptics, Chron's
disease, allergic reactions, and burns caused by foods and beverages.

Clinical Features and Manifestations

Given that stomatitis is caused my mostly poor hygiene and medical malfunction-related causes,
people with stomatitis suffer from different physical symptoms mostly seen by visible eye. Those
symptoms includes mild to severe pain that takes too long to heal. Some symptoms includes:
• Mouth ulcers with a yellow or white layer and red base, usually inside the lips, cheek, or
on the tongue — these are called trush or candidiasis. It is a fungal infection that appears as red
corners of tissue in the mouth. A white flaky layer may appear on the tongue, inside the cheeks
or gums as it progresses. Even though the white layer can be easily removed, the tissue under
looked 'raw'.
• Red patches — viruses are considered to be the most common infectious cause of mouth sores
and it can cause oral lesions as well. For example, it can an be caused by certain bacteria like
treptococcus and actinomyces that causes the red patches.
• Blisters — are often caused by skin damag due to heat or friction. There are some medical
conditions that causes blisters to appear. It happens when the damaged epidermis tears away
from the serum and collects in the space to create a blister.
• Oral dysaesthesia – a burning feeling in the mouth lesions that heal in several days but can
still reoccur.

Diagnosis
To fully diagnose the patient, the doctor will also examine the patient's history and follow up
examinations to check what type of stomatitis does the patient have and to also know if those
symptoms are really under stomatitis. These procedures are important for the sake of the patient
to have a conclusion regarding their medical state.
• Medical History — The expert would need to ask the patients regarding their medical history
in order to know if their family has a background of stomatitis. With that in hand, the doctor
might be able to diagnose stomatitis to the patient as stomatitis may be a genetic factor that
causes stomatitis to arise. On the other hand, its best to know the medical history of the patient
and see if the patient is allergic to a certain medicine, food, or beverages that causes the
appearance of stomatitis.

• Physical Examination — this is crucial for diagnosing a patient as stomatitis are mostly seen
physically. Thorough physical exam are important for a detailed diagnosis and understanding of
stomatitis as the diagnosis of the said disease is mostly clinical. Also, the location and features of
the ulcers important findings.
The exam findings that may help the diagnosis may include the following: Appearance: No
distress, Halitosis; Vitals: Normal blood pressure; Fever (in case of infectious stomatitis);
Cardiovascular: S1: normal, S2: normal, Tachycardia: HEENT: Neck tenderness, Palpable
lymph nodes, vesicles or ulcers on the tongue, vesicles or ulcers on the soft or the hard palate,
whitish areas in the buccal mucosa, Oral mucosal ulcers; Dermatological: Rash in case of diffuse
allergic reaction, gastrointestinal, and abnormal bowel sounds.

• Bacterial Culture Test — this is a test that can help find harmful bacteria inside your body
that may be the reason you are sick. The expert would need samples for the tests depending on
the location of the infection. With that, they will get a tiny sample of your urine, skin, blood,
stool, or tissue. The expert will need to examine a large number of bacteria cells to know what
type of bacteria you have. With that in hand, your sample will be sent to a laboratory and place
the bacteria until it grows enough for a test. This test is very useful in diagnosing certain types of
infection.

• Biopsy — The patient would need to undergo biopsy wherein the doctors will need to remove
small sample of affected tissue to check if there are cancerous cells that exist. There are two
main methods being used in case of suspected mouth cancer and these are punch or incision
biopsy.

Management And Treatment

The treatment options for stomatitis are the same whether the patient is palliative or curative.
Subtle variations depend on prognosis and life expectancy.
Managing stomatitis isn’t a run-of-the-mill type of thing, rather it needs to be focused on. The
patient as well as the nurse in charge would need to observe the improvements in each passing
day by following the health rules needed such as changing a part of their lifestyle that triggers
the growth of stomatitis and having a proper hygiene.

Nursing Management
• Brushing and flossing — Instruct the client to brush and afterwards floss their teeth and make
sure to massage their gums numerous times daily.
• Advise to use sponge or gauze toothette — Advise the clients to use the said oral brushes to
gently clean the oral mucosa when the patient cannot use a toothbrush because of the pain caused
by the stomatitis.
• Recommend dilute solution — its best if the nurse would suggest that the patient would use
water, dilute solution of hydrogen peroxide, or saline instead of mouthwash and toothpaste.
• Promote sufficient amount of fluid and food intake — advise the patient to eat bland diet,
suggest eating cold or lukewarm foods and fluids that reduces discomfort.

Pharmacological Management
Aside from having a good hygiene and managing the food and liquid intake, its also best to take
prescribed medicine to help treat stomatitis faster. Truth to be told, not all sores are harmless so
if the patient notice that symptoms are still visible even after taking oral medicine and proper
diet, then they must need to now see a doctor. However, for the meantime, here are some of the
oral medicine or formulas that the patient with stomatitis needs to take:
• Tetracyclines and derivatives (Doxycycline and Minocycline) — the intake of tetracycline
as an oral rinse minimize the pain associated with stomatitis and it is use to treat periodontal
disease.
• Prednisone — this is used to treat numerous conditions but in the case of stomatitis, it helps to
treat inflammation or swelling.
• Valacyclovir — Valacyclovir is mostly taken to treat herpes virus infections namely herpes
labialis (cold sores), herpes zoster (shingles), and herpes simplex (genital herpes) in adults. This
particular medicine works best if it is used within 48 hours after the first symptoms of genital
herpes or shingles begin to appear.
Surgical Management
Stomatitis doesn’t have a specific surgery as it is only an external disease and can be cured and
treated using different medications and proper hygiene. If the patient would successfully
conform to the nurse’s advice and the doctor’s prescribed medications, then it is possible that the
stomatitis would heal after a few weeks, thus, its not needed to perform any surgery.

BARRET’S ESOPHAGUS
The Barrett’s Esophagus is an internal condition in which it is marked by an anomaly in the lining of
the lower esophagus. The condition was said to happen because of the severe Gastrooesophageal
Reflux Disease or GERD. But in context, GERD patients doesn't have that kind of abnormality.
However, the existence of the said disease should not be seen lightly as patients who has Barret's
Esophagus are of greater risk of having cancer of the Esophagus. That is why it is important to take
great and careful observation of the disease. In comparison, people with GERD have this occurrences
wherein the esophagus is repeatedly exposed in too much amounts of bile and stomach acids.
Fortunately, the intestinal cells of the said disease are more resistant to acid and bile than squamous
cells which means that these cells may develop in order to protect the esophagus from too much
exposure from the acid. However, the main matter is that the intestinal cells have a high risk of
transfiguration and becoming into cancer cells. In terms of physiological aspects, the esophageal
lining or the epithelium normally consists of flat, layered cells that are the similar to those in the skin.
This esophageal lining then stops abruptly at the joint surface of the esophagus with the stomach near
the lower end of the lower esophageal sphincter. The epithelium of the rest of the gut, down to the
anus, consists of columnar epithelium, a single layer of side-by-side rectangular cells. Most of the
time, the epithelium of the esophagus down to the lower esophageal sphincter is normally squamous
but in Barrett’s esophagus, columnar epithelium protract up to different degree up into the
esophageal body. On the other hand, the most common risk factor of having Barret’s Esophagus are
based on their age, ethnic background, gender, obesity, lifestyle, and biological history.

Etiology

Given that this disease, often happens when cells are damaged by too much exposure to acid from
the stomach, the real reason behind the development of Barret's Esophagus is not quite known.
However, after numerous study, there were underlying research that says this particular condition
often develops after a long time experiencing gastroesophageal reflux (GERD). In short, the
condition was most often caused by GERD. In pathophysiologic perspective, the disease is said to be
the result of esophageal epithelial response to a specific internal injury. Acid-induced injury to the
native squamous cell epithelium of the esophagus would eventually lead to epithelial repair and in
some case, the columnar epithelium could replace the original epithelium in which it offers greater
tolerance to a very decreased amount of pH. However, it may also be a factor or a tendency towards
dysplastic change predisposing to esophageal adenocarcinoma.

With that being said, there are also underlying risk factors that intensify Barret's Esophagus 1.) If you
have GERD symptoms for longer than a decade then you have may be under a potential risk of
developing Barrett’s esophagus. 2.) being Caucasian 3.) being male 4.) being 50 years old and above
4.) having H pylori gastritis 6. ) smoking 7. ) being obese. On the other hand, there also factors that
irritate GERD and that may worsen Barrett’s esophagus. These includes smoking, frequent use of
NSAIDS, alcohol, diets in high saturated fats, spicy foods, going to bed immediately after eating, and
eating large portions during meals.

Technically, Esophageal Carcinoma, GERD, and most especially Barrets Esophagus have been
linked with obesity. The relationship between GERD (which is the major cause of Barette's
Esophagus) and obesity is said to be due to increased intra-abdominal pressure, increased
gastroesophageal sphincter gradient, and increased appearance of hiatal hernia.

A relevant and recent retrospective case-control study showcases a strong relationship between
Barrete's Esophagus and mean visceral adipose tissue when equating patients with and without
Barrete's Esophagus who had undergone both endoscopy and an abdominal CT scan in the hospital.

Clinical Features and Manifestation

Truth to be told, Barrett’s esophagus does not have any specific symptoms but since most patient
with this condition also have GERD, they will usually experience numerous internal pain in which an
individual should look after. For instance, heartburn in the presence for at least twice a week is the
biggest problem that one should pay attention. Heartburn symptoms is defined as a burning sensation
in the chest and acid regurgitation. On top of that, there are also several symptoms that may help a
person to identify when is it the right time to consult a doctor.

Other symptoms to pay attention to includes:

1. Heartburn that worsens and it wakes you from sleep. — Given that one of the major causes of
BE is GERD, GERD also has a significant symptom call acid reflux that can also be associated with
Barette's Esophagus. This usually happens when the sphincter muscle at the end of your esophagus
relaxes at the wrong time, thus, letting your stomach acid to go upwards your esophagus.

2. Painful or difficulty in swallowing. - this type of occurrence, in medical term, is called

dysphagia. This s popular known side effect of gastrointestinal disorders. Dysphagia Barrett's
esophagus patients happens when acid reflux creates scar tissue that narrows and tightens the
esophagus.

3. Sour taste in your mouth, constant sour throat or bad breath. — When the acids flow back
into your throat, the regurgitation of stomach contents may cause heartburn and a bitter and/or sour
taste in the insides of your mouth. With that being said, it is also likely that a patient may experience
bad breath as a consequence of the symptom.

4. Unintentional weight loss. — Weight loss may happen because of eating- and appetite-related
complications because of the chronic condition. Being obese can increase the risk of BE, but being
underweight can also be hazardous to health and that would even lead to a higher risk of death risk,
especially with age.
5. Blood in stool. — This result from bleeding along the GI tract which is from mouth to anus. This
happens when the bleeding rose up the upper organs of the GI tract.

6. Vomiting — The taste,intertwined with the constant burping and coughing associated with gastro
intestinal conditions may cause vomiting and nausea to the patients.

Diagnosis

For the experts to diagnose Barette’s Esophagus accurately, they should pay attention
and take good observation in the inspection of the anatomic landmarks,
squamocolumnar junction, and esophagogastric junction. With that being said, the
patient would need to undergo both endoscopy and biopsy in the Upper Gastrointestinal
Tract.

• Upper Gastrointestinal Endoscopy — In endoscopy, the gastroentologist uses an

endoscope to see the insides of your gastrointestinal tract while receiving light sedation.
Eventually, an endoscope would be inserted down the throat and it would check for any
signs of esophagus change. In context, the tissue in Barrette’s Esophagus appears velvety
and red — which is very different from the normal esophagus that is glossy and pale. To
determine the degree of tissue change, a pathologist would examine it as dysplasia is
hard to diagnose. It is suggested that two pathologists would check up on the patient
(atleast one of them specializes in gastroenterology pathology) to make an agreement to
the patient’s diagnosis). The tissue would then be classified as:

• No dysplasia — its when the BE is visible but there are no changes being found in the
cells.

• Low-grade dysplasia — this happens when the cells shows little signs of precancerous
transformation.

• High Grade Dysplasia — this is when the cells show major changes, thus, called as the
final step before the cells would transform as esophageal cancer.

• Upper Gastrointestinal Biopsy — In biopsy, there was a newly found biopsy technique
being used and its called the Wide Area Transepithelial Sampling in which the expert uses
a brush to scrape the cells from the esophageal lining. This helps the pathologists to have
a larger sample of the cell and helps diagnose disease carefully.
•Endomicroscopy — This technique is used to obtain microscopic pictures of the
esophageal tissue. The only difference of endomicroscopy and endoscopt is that the
medical health professional inserts a small camera through the endoscope. In some
cases, this procedure also identify precancerous cells in the esophagus.

Management and Treatment

Nursing Management

1.

Pharmacologic Management

The treatment of the said disease would always depend on the severity of the condition, the grade
of dysplasia, and the health of the patient. Medication and surveillance would be the priority
treatment of Barrete's Esophagus. The most common type of medication are the Proton Pump
Inhibitors. These are generally used for treating GERD as it suppresses the acid production of the
stomach. If there are less acid in the stomach, then that would mean less damage to the
esophagus. Some examples of PPI's being suggested are:
1. Omeprazole (Prilosec, Zegerid) — one study showed that the formulation of
omeprazole (40 mg) if given twice a day is able to take a hold of nocturnal esophageal
reflux in 100% patients having Barette's Esophagus and complete immediate control of
97% esophageal pH of the 24-hour recording periods.
2. Lanzoprazole (Prevacid) — the action of Lanzoprazole is to inhibit membrane enzyme
H+/K+ ATPase in the gastric parietal cells and allows to prevent and heal damage in the
esophagus.
3. Pantoprazole (Protonix) — this is mainly used to treat specific stomach and other
esophagus problems like acid reflux. The main action of this is that it decreases the
amount of acid in your stomach and helps in relieving heartburn and dysphagia.
4. Raberprazole (Aciplex) — this PPI blocks the final step of the secretion of the gastric
acid. Rabeprazole is protonated and is being transformed to an active sulfenamide in
gastric parietal cells. With that being said, it heals the probable danger caused by the
acids from the stomach.
 5. Esomeprazole (Nexium) — This is said to be the most commonly used PPI in the United
States Of America and allows the treatment of oesophagitis without promoting expansion
of clonal of Barrett's oesophagus.
6. Dexlansoprazote (Dexilant) — this is considered to he the powerful Proton Pump
Inhibitor as it ensures the longest period of drug retention in the circulation.

Surgical Management
As being mentioned from the previous section, the treatment would vary depending on the
severity of the disease. Since it is based on the severity, the treatments are then divided based on
the grade of dysplasia.

1. No Dysplasia
• Treatment for GERD — it is suggested that the patients don’t need to undergo any surgery if
there are no dysplasia but it is required for them to change their lifestyle as well as the
medications. If they are uncertain of their disease, then it would be possible for them to undergo
endoscopy.
• Periodic Endoscopy to Fully Monitor The Cells In The Esophagus — If the symptoms still
occur, it is best if the patient would consider a follow up endoscopy after a year and continue
until 3-5 years.

2. Low-Grade Dysplasia
• This particular grade of dysplasia was mentioned as the early stage of precancerous changes.
The experienced pathologist should verify if a dysplasia is found. The doctor may possibly
recommend another endoscopy in six months, with another follow-up for every six to 12 months.
• Endoscopic resection — it uses an endoscope to remove the destroyed or abnormal cells to
treat the detection of dysplasia, and worse, cancer.
• Radio frequency ablation — uses heat to remove disoriented esophagus tissue. It may
possibly may be suggested and/or recommended after endoscopic resection.
• Cryotherapy — this treatment uses an endoscope to anoint a cold gas or liquid to abnormal
cells in the esophagus. The cells are then allowed to warm up and then are get frozen again. The
cycle of thawing and freezing damages the abnormal cells.
 3. High-Grade Dysplasia
• High-grade dysplasia is thought to be the final stage in the transformation of esophageal cancer.
For the same reason, the medical expert may recommend the treatments stated in the low-grade
dysplasia namely endoscopic resection, cryotherapy or radiofrequency ablation. One option
would be surgery which undergoes the process of removing the damaged part of your esophagus
and putting the left portion to your stomach

HIATAL HERNIA
Patients with hiatal hernia suffer from a condition where a portion of the stomach rises or bulges up
to the chest through the muscle and an opening in the diaphragm. In pathophysiology, it is said that a
hiatal hernia causes the size of the hiatus to not be fixed — narrows with increased abdominal
pressure occurs. Moreover, it tears the Phrenosophageal Ligament (a fibrous layer of connective
tissue that supports the LES within the abdominal cavity). On top of that, hiatal hernia also
compromises the reflux barrier that aids LES pressure, reduces esophageal acid clearance, and
transient LEX relaxation. In other words, the aesophageal mucous membrane swells up. It bleeds
easily as a result, and leucoplakia patches develop. For many years, this condition may go away,
continue, or come back, but it has the potential to spread into the muscular of the esophagus and
include the tissues of the mediastinum, lymphatics, and adjacent glands. Eventually, the hernia is
repaired. Long-term mural fibrosis causes the development of structure, which initially appears as a
ring but later spreads to the esophageal wall, specifically ascending cesophageal fibrosis, and may
finally be several inches long, most often in children. Reflux cesophagitis was the term used to
describe this series of alterations.

There are 4 types of Hiatal Hernia:

1. TYPE I (Sliding Hiatal Hernia) — This type is the most known type of hiatal hernia. This
is when the stomach just about the section of the esophagus conjoins with the abdomen
sliding up until the chest through the hiatus. This accelerates the potential risk that
constituents for the development of GERD or Gastroesophageal Reflux Disease as numerous
patients with such condition are suffering from GERD common symptoms like heartburn.
This occurs in more than 1 in 4 individuals aged 40 and up.
2. TYPE II (Paraesophageal Hernia) —This is less common but is more concerning than
sliding hiatal hernia. Many patients with paraesophageal hernias experience having no
symptoms, thus it can be observed safely and does not necessarily require surgery. In
contrast, when this type of hiatal hernia begins to cause symptoms such as chest pain, upper
abdominal pain, and difficulty swallowing, it can be usually cured or repaired. However,
symptomatic paraesophageal hernias are at higher risk for progressing to incarceration or
ischemia — where the blood supply to the stomach is cut off — and an immediate surgical
procedure is needed.
 3. TYPE III — This type is a combination of both paraespohageal hernia and sliding hernia. It
is when the GEJ and a certain portion of a stomach have migrated or changed position until
the mediastinum.
4. TYPE IV — This is when the stomach together with the additional organ like the colon and
spleen also rupture into the test.

Etiology

Mainly, the cause of Hiatal hernia is not actually known yet there are numerous causes as to why it
occurs: 1.) This could be a condition that arises because of the weakness of the supporting tissue. 2.)
This may be associated with the backflow of the gastric acid that came from the stomach and now
rises up until the esophagus. 3.) It could also be congenital as Hiatal hernias may be acquired
naturally or from birth although this may also be experienced most especially by older people.
Generally, most experts believed that the reason for the development of hiatal hernia in an individual
is because the muscle weakens, thus losing its flexibility and elasticity. With that said, this may cause
the upper part of the stomach not to return to its original position below the diaphragm during
swallowing. On the other hand, there are also other identified predisposing factors and that includes
elevated intraabdominal pressure. This was the result of pregnancy, obesity, chronic constipation,
and COPD or chronic obstructive pulmonary disease. Moreover, factors like age, genetics, and
previous surgeries, can also play a huge role in the growth and expansion of a hiatal hernia.

Clinical Features and Manifestation

With Hiatal hernia, clinical manifestations may include multitudinous aching of certain body parts
yet not all patients of this condition would experience all of the symptoms at the same time.
Although this condition is physically bothersome, this is not that serious. Common symptoms
associated with such condition are the following:

1. Heartburn — A large hiatal hernia may let food and acid back up into the esophagus,
resulting in heartburn.
2. Regurgitation of food and liquids into the mouth — this is when food from the esophagus
into the stomach enlarges causing the foods to throw back upwards until the mouth.
3. Backflow of stomach acid into the esophagus or sliding upward into the chest.
4. Difficulty Swallowing — Hiatus Hernia may also open another problem called GERD or
Gastroesophageal reflux disease. With that said, it eventually leads to dysphagia — the result
when stomach acids leak back into the esophagus.
5. Chest or abdominal pain.
6. Feeling full soon shortly after you eat — this occurs when the rising part of the stomach
eventually twists by the diagram. In addition, a Hiatal hernia may lead to the blockage of the
intestines which causes one person to be bloated.
7. Shortness of Breath — In most cases, hiatus hernia causes the stomach to elevate up until
the chest which eventually presses the lungs too much.
8. Hematemesis, Melena, and Hematochezia — Vomiting of blood or passing of black stools
which may indicate gastrointestinal bleeding.
Hiatal Hernia has been called by experts as the “great mimic” as it resembles numerous symptoms of
other disorders. For instance, chronic coughing may be mistaken as asthma while chest pain can
sometimes be analogous to a heart attack. In fact, chest pain in heart attacks can be associated with
the buildup or blockage of plaques in the coronary arteries while in Hiatal Hernia, on the contrary,
chest tightness or pain is due to acidic substances rising up into the esophagus secondary to reduced
pressure at the LES and the elevation of the gastrointestinal junction or other parts of the stomach up
to the diaphragm. Moreover, bloating may just be seen as mere indigestion and heartburn may be
attributed to the symptoms of gastroesophageal reflux disease (GERD). Albeit Hiatal Hernia may be
similar to other diseases, they still have certain differences.

Diagnosis

Given that Hiatal Hernia can be mistaken as other types of diseases, it is important for the patient to
consult a doctor to help them know if they are suffering from the said condition. The experts would
then undergo several tests that can help diagnose the disease.

1. Barium Swallow — This involves drinking a specific liquid in which afterwards the
patients would be taking X-ray to hive succor in seeing problems in the esophagus
and stomach. This is where the experts could see if the patient is experiencing
dysphagia (for the esophagus) and ulcers, tumors, and acid reflux (in the digestive
system). Moreover, it also showcases how large the condition is and also helps to
check if there is an existing twisting of the stomach.
2. Endoscopy — This is a procedure that uses material called endoscope — a long,
flexible, and thin instrument about ½ inch — and that is used to view the upper
digestive system. The diagnose would then be mentioned when there is visible
separation between diaphragmatic impression and squamocolumnar junction
and that diaphragmatic impression is much greater than 2cm as for the
endoscope.
3. Esophageal Manometry — This type of procedure helps to measure your
esophagus’ muscle coordination and strength when you swallow. Therefore, it
would also determine if you are suffering from dysphagia. To put it simply, it
basically test the patient’s coordinate muscle movement or the motility of rhe
esophagus. The material used (also known as the catheter) measures the pressure
that the muscle creates as well as the valves in either portions of the esophagus.
4. PH Test — The Ph Test would help the expert measure the acid levels in the
esophagus and soon observe what symptoms is related to the acid that reacted
with the esophagus. This is a procedure to measure the amount of acid that flows
from the stomach up to the esophagus during a 24-hour test. This test will not
accurately tell if a person has hiatal hernia as hiatal hernia has same symptoms
with other diseases but it may help in finding one symptom related to acid leak of
the digestive system that would result in GERD, Ulcer, or Hiatal Hernia.
 5. Gastric Emptying Studies — This particular study would help examine how quick
do the food leaves the stomach. The results are significant for patients who have
been suffering from vomiting and/or nausea. Moreover, patients with hiatal hernia
would show rapid gastric emptying and it also would show evidence of tracer
regurgitation in the affected stomach and esophagus in the left mediastinum.

Management and Treatment

There are multitudinous managements for hiatal hernia and that includes nursing management,
pharmacologic intervention, and surgical repair.

Nursing Management

The nursing management refers to the roles that nursing professionals need to
possess and follow the task that they are instructed to do in order to help the patient
recovers. It is the nurse’s responsibility to observe proper patient care to the patients.
In the context of hiatal hernia patients, the nurse would not need to fully attend to the
patient if not necessary since most of the patients under hiatal hernia are not in severe
case. However, they need to make sure to observe and keep track on their foods,
activities, and lifestyle. Some of the following responsibilities of the nurse includes the
following:

2. The personal nurse should elevate the head of the bed for atleast 4-8 inch
— this helps to prevent the hernia from sliding in upward manner.
3. The nurse should advance the diet laggardly from liquid to solid food but
still keeping on track the management of nausea and vomiting — 50% of
the patient under this condition experiences dysphagia or difficulty in
swallowing that’s why its important for the nurse to attend to the patients diet.
4. The nurse should also monitor the weight and tracking of nutrition intake
— Intertwine with this procedure, it is also important to instruct the patient
while eating to eat and chew the food properly to prevent gastric motility.
5. The nurse should also instruct them to not eat foods and liquids that
decreases LES pressure like chocolate, fatty foods, tea, and alcohol.
6. The nurse should inform the patient to avoid eating at least 3 hours before
bedtime — this is to reduce the potential hazard from night time reflux.
7. If the patient is obese or overweight, the nurse should tell them to reduce
body weight — this recommendation is important to tell the patient to also
prevent too much intraabdominal pressure.
8. The nurse would also monitor some indications for surgical revision —
Emergency symptoms may arise such as vomiting, post-operative belching,
 gagging, epigastric chest pain, and abdominal distention. It is the nurse’s duty
to tell the doctor beforehand about these symptoms so the doctor would
request for immediate surgery.

Pharmacologic Management

There are numerous oral medications that are suggested or prescribed when a patient is suffering
from Hiatal Hernia. Mostly, oral medications are instructed for the patients to take every now
and then to help suppress acid secretion and here are some of the following:

 Antacids to relieve heartburn.

a. Mylanta — Mylanta contains different combinations of magnesium hydroxide,

aluminum hydroxide, and calcium carbonate that reduces acid and/or gas inside
the stomach.

 Antiemetics to help relieve nausea and vomiting.

a. Vontrol (Diphenidol) — it is commonly used to control nausea as it has an

antivertigo effect allowing the chemoreceptor trigger zone to get a hold of
vomiting and nausea.
b. Anzemet (Dolasteron) and Kytril (Granisetron) — this medication is under the
medication class called Serotonin 5-HT3 receptor antagonist. It blocks the
serotonin activity that causes vomiting and nausea.
c. Marinol (Dronabinol) — this is under the class of cannabinoids that controls the
area of the brain that is responsible for nausea, appetite, and vomiting.
d. Atarax (Hydroxyzine Pamoate) — This is under the medication mostly called
an antihistamine that blocks the substance inside the human body that causes
allergic symptoms. The side effect of this medication includes sleepiness as it
decreases activity in the brain.
e. Reglan (Metochlopramide) — this is used as an alternative for patients
suffering from gastroesophageal reflux and can be also used for patients with
hiatal hernia. It produces a rising in the lower esophageal sphincter pressure.

 Histamine H2 receptors antagonist to help suppress the secretion of gastric acid.

a. Tagamet (Cimetidine) and Zantac (Ranitidine)— Cimetidine belongs to a
medication class called H2 and its main help for hiatal hernia patients is to reduce
the amount of acid inside the stomach. It can also treat heartburn, cough, and
stomach pain.
b. Axid (Nizatidine) and Pepcid (Famotidine) — These are prescribed medicine
that is used to treat the symptoms of ADU and GERD. It may be also used alone
or with other existing medications. Just like the previous medication. Nizatidine
 is used for reducing the gas inside the stomach and relieves coughing, stomach
pain, and dysphagia — the most common symptoms of Hiatal Hernia.

 Proton pump inhibitors to subdue the secretion of acid secretion.

a. esomeprazole (Nexium), pantoprazole (Protonix), omeprazole (Prilosec), and
lansoprazole (Prevacid) — are frequently prescribed as they all prevent the
stomach lining's parietal cells from secreting acid in the same way. They also
work just as well to treat esophagitis, which is an inflammation of the esophagus
and get rid of symptoms.

Surgical Management
Not all patients with hiatal hernia need to undergo surgery as some of them may able to get well
with just only oral medication and changes in lifestyle. However, if the patient needs immediate
repair, there are three types of surgery suggested for the patient. This includes Nissen
Fundoplication, Endoluminal Fundoplication, and Open Surgery.

 Nissen Fundoplication — This is a very common surgery for Hiatal Hernia which only
requires a few incisions in the abdomen through the insertion of a thin tube that has a
light and camera attached (laparoscrope) inside the abdomen to be able to repair the
hernia. In such a way, this type of surgery draws more advantages as it lessens the risk of
infection, scarring, and shortens recovery time,
 Open Surgery — In open surgery, unlike Nissen Fundoplication, makes a much larger
incision in the stomach to help the surgeon to be able to fix the hernia. The surgeon then
pulls the stomach up until the abdominal cavity and covers the fundus just about the latter
part of the food pipe. This procedure makes a tight sphincter that would eventually stop
the leaking of stomach acid into the food pipe.
 Endoluminal Fundoplication — this treatment has less risk but it’s also uncommon as
the endoluminal devices are not that relatable and numerous people still experience
symptoms even after the procedure. In this procedure, the surgeon will not open the
stomach but instead, they would place an endoscope down the throat reaching the food
pipe. The surgeon would then tighten the are where the esophagus and stomach join to
control and prevent reflux.