Health Alterations II Management of Clients with Problems of the Gastrointestinal System

1. Health Alterations IIManagement of Clients with Problems of the Gastrointestinal System Lecture 2.2 Disorders of the Esophagus

2. The main symptoms of the esofageal disorders: • Dysphagia (difficulty swallowing) • Odynophagia (acute pain on swallowing)

3. Achalasia • Achalasia is an absent or ineffective peristalsis of the distal esophagus,accompanied by failure of the esophageal sphincter to relaxin response to swallowing

4. Clinical Manifestations • difficulty in swallowing both liquids and solids • sensation of food sticking inthe lower portion of the esophagus • regurgitation of food • chest pain or heart-burn (pyrosis). This pain may or may not be assotiated with eating

5. Assessment and Diagnostic Findings • X-ray (dilatation above the narrowing). CT of the esofagus, barium swallowing, endoscopy may be used too • diagnosis is confirmed by manometry

6. Management • The patient should be instructed to eat slowly and to drink fluids with meals. • As a temporary measure, calcium channel blockers and nitrates have been used to decrease esophageal pressure and improve swallowing. • Injection of botulinum toxin (Botox) to quadrants of the esophagus via endoscopy has been helpful because it inhibits the contraction of smooth muscle. Periodic injections are required to maintain remission. • If these methods are unsuccessful, pneumatic (forceful) dilation or surgical separation of the muscle fibers may be recommended

7. Achalasia may be treated conservatively by pneumatic dilation to stretch the narrowed area of the esophagus (fig. 1) • Pneumatic dilation has a high success rate. Although perforation is a potential complication, its incidence is low • The procedure can be painful; therefore, moderate sedation in the form of an analgesic or tranquilizer, or both, is administered for the treatment • The patient is monitored for perforation. Complaints of abdominal tenderness and fever may be indications of perforation

8. Fig. 1. Pneumatic dilation of the lower part of the esophagus

9. Achalasia may be treated surgically by esophagomyotomy (Fig. 2). The procedure usually is performed laparoscopically, either with a complete lower esophageal sphincter myotomy and an antireflux procedure, or without an antireflux procedure • The esophageal muscle fibers are separated to relieve the lower esophageal stricture. • Although patients with a history of achalasia have a slightly higher incidence of esophageal cancer, long-term follow-up with esophagoscopy for early detection has not proved beneficial

10. Fig. 2. Esophagomyotomy

11. Diffuse Spasm • Diffuse spasm is a motor disorder of the esophagus • The cause is unknown, but stressful situations can produce contractions of the esophagus • It is more common in women and usually manifests in middle age

12. Clinical Manifestations • Difficulty or pain on swallowing (dysphagia, odynophagia) • Chest pain similar to that of coronary artery spasm

13. Assessment and Diagnostic Findings • Esophageal manometry, which measures the motility of the esophagus and the pressure within the esophagus, indicates that simultaneous contractions of the esophagus occur irregularly • Diagnostic x-ray studies after ingestion of barium show separate areas of spasm

14. Management • Conservative therapy includes administration of sedatives and long-acting nitrates to relieve pain • Calcium channel blockers have also been used to manage diffuse spasm • Small, frequent feedings and a soft diet are usually recommended to decrease the esophageal pressure and irritation that lead to spasm • Dilation performed by bougienage (use of progressively sized flexible dilators), pneumatic dilation, or esophagomyotomy may be necessary if the pain becomes intolerable

15. Hiatal Hernia • In a condition known as hiatus (or hiatal) hernia, the opening in the diaphragm through which the esophagus passes becomes enlarged, and part of the upper stomach tends to move up into the lower portion of the thorax • Hiatal hernia occurs more often in women than men

16. There are two types of hiatal hernias: sliding and paraesophageal Sliding, or type I, hiatal hernia occurs when the upper stomach and the gastroesophageal junction (GEJ) are displaced upward and slide in and out of the thorax (Fig. 3a). About 90% of patients with esophageal hiatal hernia have a sliding hernia. A paraesophageal hernia occurs when all or part of the stomach pushes through the diaphragm beside the esophagus (see Fig. 3b)

17. Fig. 2. The Hiatal Hernia Types

18. Clinical Manifestations • Sliding hernia: heartburn, regurgitation, and dysphagia, but at least 50% of patients are asymptomatic. Sliding hiatal hernia is often implicated in reflux • Paraesophageal hernia: sense of fullness after eating or asymptomatic. Reflux usually does not occur, because the gastroesophageal sphincter is intact • The complications of hemorrhage, obstruction, and strangulation can occur with any type of hernia

19. Assessment and Diagnostic Findings • Diagnosis is confirmed by x-ray studies, barium swallow, and fluoroscopy

20. Management • Management for an axial hernia includes frequent, small feedings that can pass easily through the esophagus. The patient is advised not to recline for 1 hour after eating, to prevent reflux or movement of the hernia, and to elevate the head of the bed on 4- to 8-inch (10- to 20-cm) blocks to prevent the hernia from sliding upward. Surgery is indicated in about 15% of patients • Medical and surgical management of a paraesophageal hernia is similar to that for gastroesophageal reflux; however, paraesophageal hernias may require emergency surgery to correct torsion (twisting) of the stomach or other body organ that leads to restriction of blood flow to that area

21. Diverticulum Clinical Manifestations • Symptoms experienced by the patient with a pharyngoesophageal pulsion diverticulum include difficulty swallowing, fullness in the neck, belching, regurgitation of undigested food, and gurgling noises after eating. When the patient assumes a recumbent position,undigested food is regurgitated, and coughing may be caused by irritation of the trachea. Halitosis and a sour taste in the mouth are also common because of the decomposition of food retained in the diverticulum • Symptoms produced by midesophageal diverticula are less acute. One third of patients with epiphrenic diverticula are asymptomatic, and the remaining two thirds complain of dysphagia and chest pain • Dysphagia is the most common complaint of patients with intramural diverticulosis

22. Assessment and Diagnostic Findings • A barium swallow may be performed to determine the exact nature and location of a diverticulum • Manometric studies are often performed for patients with epiphrenic diverticula to rule out a motor disorder • Esophagoscopy usually is contraindicated because of the danger of perforation of the diverticulum, with resulting mediastinitis • Blind insertion of a nasogastric tube should be avoided

23. Management • Because pharyngoesophageal pulsion diverticulum is progressive, the only means of cure is surgical removal of the diverticulum • Postoperatively, the patient may have a nasogastric tube inserted at the time of surgery. • The surgical incision must be observed for evidence of leakage from the esophagus and a developing fistula. Food and fluids are withheld until x-ray studies show no leakage at the surgical site • The diet begins with liquids and progresses as tolerated • Surgery is indicated for epiphrenic and midesophageal diverticula only if the symptoms are troublesome and becoming worse • Treatment consists of a diverticulectomy and long myotomy • Intramural diverticula usually regress after the esophageal stricture is dilated

24. Perforation • Perforation may result from stab or bullet wounds of the neck or chest, trauma from motor vehicle crash, caustic injury from a chemical burn, or inadvertent puncture by a surgical instrument during examination or dilation

25. Clinical Manifestations • The patient has persistent pain followed by dysphagia • Infection, fever, leukocytosis, and severe hypotension may be noted • In some instances, signs of pneumothorax are observed

26. Assessment and Diagnostic Findings • Diagnostic x-ray studies and fluoroscopy are used to identify the site of the injury

27. Management • Broad-spectrum antibiotic therapy • A nasogastric tube is inserted to provide suction and to reduce the amount of gastric juice that can reflux into the esophagus and mediastinum • Nothing is given by mouth • Surgery may be necessary to close the wound, and postoperative nutritional support then becomes a primary concern • Depending on the incision site and the nature of surgery, the postoperative nursing management is similar to that for patients who have had thoracic or abdominal surgery

28. Gastroesophageal Reflux Disease (GERD) • Some degree of gastroesophageal reflux (back-flow of gastric or duodenal contents into the esophagus) is normal in both adults and children • Excessive reflux may occur because of an incompetent lower esophageal sphincter, pyloric stenosis, or a motility disorder • The incidence of reflux seems to increase with aging

29. Clinical Manifestations • pyrosis (burning sensation in the esophagus) • dyspepsia (indigestion) • regurgitation • dysphagia or odynophagia (difficulty swallowing, pain on swallowing) • hypersalivation • esophagitis • the symptoms may mimic those of a heart attack

30. Assessment and Diagnostic Findings • endoscopy or barium swallow to evaluate damage to the esophageal mucosa • ambulatory 12- to 36-hour esophageal pH monitoring is used to evaluate the degree of acid reflux • bilirubin monitoring (Bilitec) is used to measure bile reflux patterns

31. Management • Teaching the patient to avoid situations that decrease lower esophageal sphincter pressure or cause esophageal irritation • The patient is instructed to eat a low-fat diet; to avoid caffeine, tobacco, beer, milk, foods containing peppermint or spearmint, and carbonated beverages; to avoid eating or drinking 2 hours before bedtime; to maintain normal body weight • To avoid tight-fitting clothes; to elevate the head of the bed on 6- to 8-inch (15- to 20-cm) blocks; and to elevate the upper body on pillows • Medications such as antacids or histamine receptor blockers, proton pump inhibitors, prokinetic agents, which accelerate gastric emptying • If medical management is unsuccessful, surgical intervention may be necessary

32. Barrett’s Esophagus • It is believed that long-standing untreated GERD may result in a condition known as Barrett’s esophagus. This has been identified as a precancerous condition that, if left untreated, can result in adenocarcinoma of the esophagus, which has a poor prognosis • It is more common among middle-aged white men; however, the incidence is increasing among women and among African Americans

33. Clinical Manifestations • The patient complains of symptoms of GERD, symptoms related to peptic ulcers or esophageal stricture, or both

34. Assessment and Diagnostic Findings • EGD is performed. This usually reveals an esophageal lining that is red rather than pink. Biopsies are taken, and the cells resemble those of the intestine

35. Management • Monitoring varies depending on the amount of cell changes. Some physicians may recommend a repeat EGD in 6 to 12 months if there are minor cell changes • Medical and surgical management is similar to that for GERD

36. Nursing Process Assessment • Emergency conditions of the esophagus (perforation, chemical burns) usually occur in the home or away from medical help and require emergency medical care • The patient is treated for shock and respiratory distress and transported as quickly as possible to a medical facility • Foreign bodies in the esophagus do not pose an immediate threat to life unless pressure is exerted on the trachea, resulting in dyspnea or interfering with respiration, or unless there is leakage of caustic alkali from a battery • Educating the public to prevent inadvertent swallowing of foreign bodies or corrosive agents is a major health issue

37. For nonemergency symptoms, a complete health history may reveal the nature of the esophageal disorder • The nurse asks about the patient’s appetite. Has it remained the same, increased, or decreased? • Is there any discomfort with swallowing? If so, does it occur only with certain foods? Is it associated with pain? Does a change in position affect the discomfort? • The patient is asked to describe the pain. Does anything aggravate it? Are there any other symptoms that occur regularly, such as regurgitation, nocturnal regurgitation, eructation (belching), heartburn, substernal pressure, a sensation that food is sticking in the throat, a feeling of becoming full after eating a small amount of food, nausea, vomiting, or weight loss? Are the symptoms aggravated by emotional upset?

38. If the patient reports any of these symptoms, the nurse asks about the time of their occurrence, their relationship to eating,and factors that relieve or aggravate them (eg, position change, belching, antacids, vomiting) • This history also includes questions about past or present causative factors, such as infections and chemical, mechanical, or physical irritants; the degree to which alcohol and tobacco are used; and the amount of daily food intake • The nurse determines whether the patient appears emaciated and auscultates the patient’s chest to determine whether pulmonary complications exist

39. Nursing Diagnosis • Based on the assessment data, the nursing diagnoses may include the following: • Imbalanced nutrition, less than body requirements, related to difficulty swallowing • Risk for aspiration related to difficulty swallowing or to tube feeding • Acute pain related to difficulty swallowing, ingestion of an abrasive agent, tumor, or frequent episodes of gastric reflux • Deficient knowledge about the esophageal disorder, diagnostic studies, medical management, surgical intervention, and rehabilitation

40. Planning and Goals • The major goals for the patient may include attainment of adequate nutritional intake, avoidance of respiratory compromise from aspiration, relief of pain, and increased knowledge level

41. Nursing Interventions • Encouraging adequate nutritional intake • Decreasing risk of aspiration • Relieving pain • Providing patient education • Promoting home and community-based care: Teaching patients self-care Continuing care

42. Evaluation Expected patient outcomes may include: 1. Achieves an adequate nutritional intake a. Eats small, frequent meals b. Drinks water with small servings of food c. Avoids irritants (alcohol, tobacco, very hot beverages) d. Maintains desired weight 2. Does not aspirate or develop pneumonia a. Maintains upright position during feeding b. Uses oral suction equipment effectively

43. 3. Is free of pain or able to control pain within a tolerable level a. Avoids large meals and irritating foods b. Takes medications as prescribed and with adequate fluids (at least 4 ounces), and remains upright for at least 10 minutes after taking medications c. Maintains an upright position after meals for 1 to 4 hours d. Reports that there is less eructation and chest pain 4. Increases knowledge level of esophageal condition, treatment, and prognosis a. States cause of condition b. Discusses rationale for medical or surgical management and diet or medication regimen c. Describes treatment program d. Practices preventive measures so injuries are avoided

44. Thank You For Your Attention!