NCM 116: CARE OF CLIENTS WITH PROBLEMS IN NUTRITION AND GASTROINTESTINAL

Digestive and Gastrointestinal Specific

Disorders:
ESOPHAGEAL DISORDERS
(ORAL)

Inst. Marlo N. Bobier, RM, RN, MAN

01
HIATAL HERNIA
Hiatal Hernia
● A hiatal hernia is a condition where a portion of
the stomach protrudes through the diaphragm
into the thoracic cavity via an opening known as
the hiatus. This abnormal displacement can lead
to gastrointestinal symptoms, particularly
gastroesophageal reflux disease (GERD), due to
compromised function of the lower esophageal
sphincter (LES).
● It is more often in women
● Has 2 types
○ Sliding Hiatal Hernia
○ Paraesophageal Hernia
EPIDEMIOLOGY
A hiatal hernia can develop in people of all ages and
both sexes, although it frequently occurs in people
aged 50 and older. Hiatal hernia occurs more often in
people with overweight/obesity and smokers.
 CAUSES
Increased pressure within the abdomen caused by:
• Heavy lifting or bending over
• Frequent or hard coughing
• Hard sneezing
• Pregnancy and delivery
• Vomiting
• Constipation
• Obesity
 CAUSES
Increased pressure within the abdomen caused by:
• Permanent shortening of esophagus – which pulls the
stomach up
• Muscle weaking from aging
• Congenital defect
• Diet – gas producing foods – cause distention of
stomach-apply pressure on diaphragm and increases
the risk of herniation
• Foods which weakens the muscle tone – white flour,
refined sugar and sugar products, preservatives,
alcohol, tea, coffee – increases the risk of herniation
• Smoking
 TYPES OF HIATAL HERNIA
SLIDING HIATAL HERNIA PARAESOPHAGEAL HERNIA
• The upper stomach and the GE junction are displaced • All or part of the stomach pushes through the diaphragm
upward and slide in and out of the thorax beside the esophagus

• The primary cause of sliding hiatal hernia is muscle

weakness in the esophageal hiatus (the opening
between the two domes of diaphragm where the
esophagus enters the abdominal cavity). This may be • This type of hiatal hernia is due to anatomic defect
due to aging process, congenital muscle weakness,
obesity, trauma, surgery, or prolonged increases in
intraabdominal pressure like heavy lifting and obesity.

• 50% asymptomatic • Sense of fullness or chest pain after eating

• Heartburn, regurgitation, dysphagia, and reflux • Usually reflux does not occur
PATHOPHYSIOLOGY
 CLINICAL MANIFESTATIONS
1. Heartburns due to gastroesophageal reflux
2. Dysphagia (Difficulty swallowing), odynophagia (painful swallowing)
are due to the compression of the esophagus.
3. Dyspnea due to compression of the lungs.
4. Abdominal pain due to compression of the protruding portion of the
stomach.
5. Nausea and vomiting due to stimulation of sensitive structures in the
stomach.
6. Gastric distention, belching, flatulence due to accumulation of gas in
the stomach and abdomen. This is caused by impaired mobility.
 DIAGNOSTIC TESTS
1. X-ray Studies
2. Barium Swallow
3. Fluoroscopy - Real time image of internal part of the body over a
short period of time.
 MANAGEMENT

1. MEDICATIONS
a. Antacids to relieve heartburns
b. Antiemetics to relieve nausea and vomiting.
c. Histamine H₂ receptor antagonists to suppress secretion of
gastric acid.
d. Proton pump inhibitors to suppress gastric acid secretion.
v The patient with hiatal hernia should avoid drugs that lower LES pressure. To
prevent gastroesophageal reflux. The drugs to be avoided by the client are as
follows: anticholinergics, Xanthine derivatives, calcium - channel blockers and
diazepam.
 MANAGEMENT
2. NURSING INTERVENTIONS
• Relieve pain by administering antacids.
• Modify diet.
o High protein diet to enhance LES pressure and prevent
esophageal reflux.
o Small frequent feedings to prevent gastric distention. These,
also prevent further protrusion of the stomach into the thoracic
cavity.
o Instruct the patient to eat slowly and chew food properly. To
reduce gastric motility.
o The patient should avoid foods and beverages that decrease
LES pressure like fatty foods, cola beverages, coffee, tea,
chocolate, alcohol.
 MANAGEMENT
o The patient should assume upright position before and after eating
for 1 to 2 hours. This prevents protrusion of the stomach in the
thoracic cavity and prevents reflux.

o Instruct the client to avoid eating at least 3 hours before bedtime. To

prevent night time reflux.
o Instruct the patient to reduce body weight, if obese. To reduce
intraabdominal pressure.
 MANAGEMENT

o Advise the patient to promote lifestyle changes:

§ Elevate head of bed to 6 to 12 inches for sleep.
§ Avoid factors that increase abdominal pressure like use
of constrictive clothing, straining at stool, heavy lifting,
bending, stooping, and vigorous coughing. If coughing
cannot be avoided, follow through with open mouth.
§ Avoid cigarette smoking. Smoking causes rapid and
significant drop in LES pressure.
 MANAGEMENT

3. SURGERY
• The surgical procedure for Hiatal Hernia is Nissen Fundoplication
or Gastric Wrap-Around
Ø This procedure involves using stitches to wrap the upper part
of the stomach, called the fundus, around the bottom portion
of the esophagus in order to hold the stomach in place below
the diaphragmatic hiatus. The stitches create pressure at the
end of the esophagus which prevents stomach acid and food
from flowing up from the stomach.
 MANAGEMENT
Nissen Fundoplication or Gastric Wrap-Around
Nissen Fundoplication or Gastric Wrap-Around
 MANAGEMENT
• Collis-Nissen Gastroplasty
Ø This surgery is used to lengthen the esophagus in patients
with more complex forms of Hiatal hernia due to esophageal
shortening. In this procedure, a surgeon will use tissue from
the upper part of the stomach to extend the esophagus.
 COMPLICATIONS

• Dysphagia
• Esophagitis
• Gastroesophageal reflex
• Infection or bleeding
• Damage of the internal organ e.g. heart, lungs, etc.
 HEALTH EDUCATION
1. Encourage the patient to delay lying down for 3 to 4 hours after
eating
2. Avoid acidic foods like orange juice, tomato sauce, and soda
3. Limit fried and fatty foods, alcohol, vinegar, chocolate, and
caffeine
4. Small frequent meals
5. Sleep in head elevated position (reverse trendelenberg) with
extra pillows to avoid reflux of food and to reduce
intraabdominal pressure
6. Don’t wear tight belts or clothes that put pressure on the
stomach
7. Encourage weight loss
8. Smoking cessation
 NURSING PROCESS
The nursing process for managing a patient with a hiatal hernia includes:

Assessment: Gather comprehensive health history and symptomatology; monitor

vital signs and nutritional status.
Diagnosis: Identify nursing diagnoses such as impaired swallowing or ineffective
health management related to dietary habits.
Planning: Develop individualized care plans focusing on symptom management
and lifestyle modifications.
Implementation: Educate patients on dietary changes, medication adherence, and
when to seek medical attention for worsening symptoms.
Evaluation: Assess patient outcomes regarding symptom relief and adherence to
management strategies; adjust care plans as necessary based on feedback
02
GASTROESOPHAGEAL
REFLUX DISEASE
(GERD)
Gastroesophageal Reflux
Disease (GERD)
● Gastroesophageal reflux disease
(GERD) is a chronic gastrointestinal
disorder characterized by the
retrograde flow of gastric contents
into the esophagus, leading to
symptoms such as heartburn and
regurgitation. It can manifest as either
non-erosive reflux disease (NERD) or
erosive esophagitis, depending on the
presence or absence of muco s a l
damage observed during endoscopy.
 EPIDEMIOLOGY
• GERD occurs in all ages but, most common in those older
than 40 years of age
• About 10-20% of people in western countries suffer from
GERD symptoms on a weekly basis
• About 7% have symptoms on a daily basis
• Except for NERD (Nonerosive reflux disease) and
pregnancy, no much difference in incidence between men
and women
• But for Barrett’s esophagus, prevalence is more in males
particularly white adult males.
 RISK FACTORS
• Nicotine
• High-Fat Foods
• Xanthine – derivatives (Theophylline, Caffeine, Tea)
• Ganglionic Stimulants
• Beta adrenergic agents
• Elevated estrogen/progesterone levels
 PATHOPHYSIOLOGY
1. DECREASED LOWER ESOPHAGEAL SPHINCTER PRESSURE

Ø Primary barrier to gastro esophageal reflux is the lower

esophageal sphincter
Ø LES normally works in conjunction with the diaphragm
Ø If barrier disrupted, acid goes from stomach to esophagus
Ø May be due to
• Spontaneous transient LES relaxations
• Transient increase in intra abdominal pressure
• An atonic LES
 PATHOPHYSIOLOGY
Ø FACTORS AFFECTING LES TONE
o Drugs that reduce LES tone include calcium channel
antagonists (e.g., nifedipine, verapamil, diltiazem),
nitrates, anticholinergic agents(e.g., tricyclic
antidepressants, antihistamines), and oral
contraceptives and estrogen.
o Foods that reduce LES tone include chocolate, fatty
foods, onions, peppermint, and garlic
o Smoking(nicotine) reduces LES tone.
 PATHOPHYSIOLOGY
2. DISRUPTION OF ANATOMICAL BARRIERS
Ø Associated with hiatal hernia
Ø The size of hiatal hernia is proportional to the frequency of LES
relaxations
Ø Hypotensive LES pressures and large hiatal hernia- more chance of
GERD following abrupt increase in intra abdominal pressure

3. ESOPHAGEAL CLEARANCE
Ø The Gl acid produced spent too much time in contact with the
esophageal mucosa
Ø Normally swallowing contributes to esophageal clearance by
increasing salivary flow
Ø Saliva decreases with increasing age, so more often seen with
elderly.
 PATHOPHYSIOLOGY
4. MUCOSAL RESISTANCE
Ø The mucus secreted by the mucus secreting glands involves in the
protection of esophagus
Ø The bicarbonates moving from the blood to the lumen can neutralize
acidic refluxate in the esophagus. On repeated exposure to the
refluxate or due to some defect in normal mucosal defenses
hydrogen ions diffuse into the mucosa, leading to cellular
acidification and necrosis leading to esophagitis.

5. DELAYED GASTRIC EMPTYING

Ø An increase in gastric volume may increase both the frequency of
reflux and the amount of gastric fluid available to be refluxed
Ø Physiologic Postprandial Gastro esophageal reflux occurs
 PATHOGENESIS
Amount of esophageal damage seen dependent on:
• Composition of refluxed material
• Volume of refluxed material
• Length of contact time
• Natural sensitivity of esophageal mucosa
• Rate of gastric emptying
 DIAGNOSTIC TESTS
• Barium Swallow
• Endoscopy
• Ambulatory pH monitoring
• Acid perfusion (Bernstein test)
• Esophageal manometry
 DIAGNOSTIC TESTS
• Ambulatory pH monitoring
Ø A 24-hour pH study is often done in
conjunction with the esophageal manometry
to monitor the levels and changes in acid
content over a 24-hour period, while the
patient conducts his or her normal daily
activities.
 DIAGNOSTIC TESTS
• Ambulatory pH monitoring
 DIAGNOSTIC TESTS
• Acid Perfusion (Bernstein Test)
Ø A nasogastric (NG) tube is passed through one side of
the nose and into the esophagus. Mild hydrochloric
acid will be sent down the tube, followed by saline
solution. The process may be repeated several times.
Ø Onset of symptoms after ingestion of dilute
hydrochloric acid and saline is considered positive.
 DIAGNOSTIC TESTS
• Acid Perfusion (Bernstein Test)
 CLINICAL MANIFESTATIONS
v Mimic the symptoms of heart attack
1. Pyrosis (Heartburn)
2. Dyspepsia (Indigestion)
3. Regurgitation
4. Dysphagia or odynophagia
5. Hypersalivation
6. Esophagitis

Esophagitis – inflammation of the

esophagus
 MANAGEMENT
• Antacids – over the counter acid suppressants and
antacids appropriate initial therapy
• Histamine blockers – competitively block the histamine
receptors in gastric parietal cells, thereby preventing acid
secretion
• Bethanecol - stimulate lower esophageal sphincter
pressure and enhance acid clearance mechanisms
• Metoclopramide (Reglan) - decreases the reflux of
stomach acid by strengthening the muscle of the lower
esophageal sphincter.
 MANAGEMENT
• Lifestyle Modifications
o Small frequent feedings
o Fluids with meals
o Eat slowly and chew food thoroughly
o Avoid very hot or cold foods, spices, fats, alcohol,
coffee, chocolates, citrus juices, eating and drinking 3
hours before retiring at night.
o Elevate head of bed 6-8 inches
o Weight reduction
o Avoid tobacco, salicylates, phenylbutazone.
 MANAGEMENT
• Surgery:
Belsey's Repair (Mark IV)
Nissen's Fundoplication Hill’s Operation
 COMPLICATIONS
• Erosive esophagitis
• Esophageal strictures and ulcers
• Hemorrhage
• Perforation
• Aspiration
• Development of Barrett’s esophagus
• Precipitation of an asthma attack
 NURSING PROCESS
The nursing process for managing a patient with GERD involves:

Assessment: Gather comprehensive data on symptoms, dietary habits, and

medication history.
Diagnosis: Identify nursing diagnoses such as "Ineffective Health Maintenance"
related to dietary habits or "Acute Pain" related to esophageal irritation.
Planning: Develop a care plan that includes education on lifestyle modifications
and medication adherence.
Implementation: Execute interventions based on the care plan while providing
ongoing education and support.
Evaluation: Assess patient outcomes regarding symptom relief and adherence to
management strategies; adjust the care plan as necessary based on patient
03
ACHALASIA
Achalasia
● Impaired motility of the lower
2/3 of the esophagus
● LES fails to relax with
swallowing
● Occurs mostly in 40 years old
and above
● Also known as esophageal
aperistalsis/achalasia
cardia/cardiospasm
 EPIDEMIOLOGY
• Incidence – 1:100,00 population
• Prevalence greatly exceeds its incidence;
estimates range from 7.1 – 13.4/100,000.
• Male = Female, but some evidence said that the
disease is more in females.
• Age – any age but typically occurs in middle age
25 – 60 year old
 CAUSES
• Hereditary
• Degeneration of nerves in the esophagus – lack of
nervous stimulation to esophagus
• Autoimmune condition, in which body’s immune
system mistakenly attacks healthy cells in the
body
• Trauma to esophageal nerve
• Infections
• Cancer of esophagus
PATHOPHYSIOLOGY
In achalasia, the balance between excitatory and inhibitory
neurotransmitters is disrupted. The excitatory
neurotransmitter acetylcholine remains active while
inhibitory neurotransmitters like nitric oxide and
vasoactive intestinal peptide are deficient. This imbalance
leads to:
- Increased resting pressure of the LES.
- Absence of peristaltic contractions in the esophagus.
- Dilation of the esophagus above the LES due to retained
food.
 PATHOLOGY
• Early in the course of the disease there is:
• Destruction of ganglion cells in the esophageal
wall.
• Disintegration of the axoplasm and myelin
sheaths within the vagus nerve
• Degenerative changes in the dorsal motor
nucleus of the vagus.
• Normal myositis of the esophagus.
 DIAGNOSTICS
• Confirmatory = Manometry (measures the esophageal
pressure)
 DIAGNOSTICS
• X-ray = shows esophageal dilation
• Barium swallow, Chest CT, and Endoscopy
 CLINICAL MANIFESTATIONS
• Heartburn (pyrosis) and chest pain
• Difficulty swallowing
• Sensation of food sticking in the lower
portion of the esophagus
• Regurgitation
• Weight Loss
• Aspiration Pneumonia
 MANAGEMENT

1. Eat slowly and to drink fluids with meals

2. Calcium channel blockers and nitrates
Ø decrease esophageal pressure
3. Botulinum toxin (Botox)
Ø inhibits the contraction of smooth muscle
4. Pneumatic dilation
Ø stretch the narrowed area of the esophagus
MANAGEMENT- Endoscopic Ballon Dilation
 MANAGEMENT
5. Esophagomyotomy (Heller Myotomy)
Ø Relieve the lower esophageal stricture by separating the
esophageal muscle fibers
 MANAGEMENT
6. MEDICATIONS
COMPLICATIONS
• Esophageal carcinoma – Malignant cells form
in tissue of esophagus
• Esophageal stricture from reflux esophagitis
• Esophagitis: Inflammation due to retained food
or reflux.
• Esophageal Dilation: Leading to increased risk
of aspiration.
NURSING PROCESS
1. Assessment:
- Evaluate symptoms (dysphagia, weight loss), Monitor vital signs and nutritional status.
2. Diagnosis:
- Identify nursing diagnoses such as impaired swallowing and risk for aspiration.
3. Planning:
- Develop a care plan that includes dietary modifications and symptom management
strategies.
4. Implementation:
- Educate the patient on dietary changes and medication adherence. Provide emotional
support and resources for coping with chronic illness.
5. Evaluation:
- Reassess symptoms regularly to determine if interventions are effective and adjust the
care plan as needed.