Disorders of the Esophagus
Terms
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- Mechanical dysphagia
- congennital defects, CA, hiatal hernia;first with solids, then semisolids, then own secretions
- Histamine Receptor Antagonists
- inhibit histamine action; inhibits gastric acid secretion; may cause thrombocyytopenia (low platelets)
- Surgical management for diverticula
- cervical approach for zenker's divertuculum, thoracic approach for diverticula in lower esophagus, diverticulum is excised and esophageal mucosa is reanastomosed, cut out and put two ends back together
- hiatal hernia types
- Sliding hernias (type I), rolling or paraesophageal hernias (typeII)
- Esophagogastrostomy
- resecting the lower portion of the esophagus and anastomosing the remainder to the stomach brought up into the thorax
- Angelchick prosthesis
- synthetic C-shaped silicoone prosthesis is tied around the distal esophagus, prostesis anchors the LES in the abdomen and reinforces sphincter pressure
- ND for diverticula
- risk for altered respiratory function, acute pain, risk for FVD or FVE, risk for injury, PC's: electrolyte abnormality; atelectasis; DVT; paralytic ileus; infection
- Diverticula
- saclike outpouching in one or more layers of the esophagus, as food is ingested, it becomes trapped in a diverticulum and can later be regurgitated, Zenker's diverticulum is most common
- Dietary management for GERD
- Small frequent meals, aadequate fluids at meals, eat slowly and chew thoroughly, avoid extremes, avoid eating and drinking 3 hrs prior to bed, elevate HOB 6-8 inches, lose wt if overweight
- interventions for diverticula
- pre/post- op teaching, NG tube care, Do not irrigage or reposition NG unless physician ordered, IV fluids, pain control, assess for s/s esophageal perforation: chest pain, elevated temp, SQ emphysema
- Odynophagia
- painful swallowing, usually severe, deep, long lasting and may radiate to neck, back upper thorax and shoulder, may be triggered by a cold or carbonated beverage
- Medical management for GERD
- Antacids, histamine receptor antagonists, cholinergics, prokinetic agents, proton pump inhibitor, AVOID anticholinergic drugs, Ca+ channel blockers, theophyline, valium cuz of decrease inLES pressure and delay in gastric emptying
- S/S of GERD
- heartburn, odynophagia, dysphagia, acid regurgitation, eructation
- Esophageal dilation
- dilating the LES; usually done as outpatient; also corrects esophageal spasms adn strictures
- interventions for esophageal neoplasms
- qd wt, diet change/feedings, provide emotional support, assist client/family to prepare for death
- Dyspepsia
- AKA indigestion or heartburn, painful sensation of warmth and burning in the lower retrosternal midline
- Nursing diagnosis for surgical management for GERD
- risk for altered respiratory function, acute pain, risk for FVD or FVE, risk for injury, PC's: electrolye imbalance, atelectasis; DVT; paralytic ileus; infection
- Dysphagia
- Difficulty swallowing, mechanical, cardiovascular, neurologic
- Endoscopy
- evaluation appearance of gastric mucosa
- Rolling or paraesophageal hernias type II
- the gastroesophageal juncion stays below the diaphragm, but all or part of the stomach pushes through into the thorax, c/o fullness after eating or difficulty beathing; also pain when in recumbent position
- ND: Altered comfort
- position changes to reduce pressure while eating, dietary changes, daily wts, medication administration
- Antacids
- neutralize gastric acid; coats GI tract, take 1hr ac and 2-3 hr pc so pH remains constant, given immediately after meals delays gastric emptying, can bring pH up to 3 (normal 1.5)
- Achalasia
- disorder characterized by progressively increasing dysphagia, 20s and 30s, men=women, unknown cause, impaired motility of the lower tow thirds of the esophagus, regurgitation of undigested food eaten many hours earlier as well as large amounts of mucous
- Esophagectomy
- removal of all or part of the esophagus and replaced with dacron graft
- S/S of esophageal neoplasms
- dysphagia, odynophagia and/or wt loss
- Esophageal neoplasms
- cancer of esophagus, usually squamous cell carcinoma or adenocarcinoma, links to heavy smoking, nutritional deficiencies, habitual ingestion of alcohol, hot foods/drinks, expand locally and very rapidly with early spread ro lymph nodes, pulmonary complications common due to development of tracheoesophageal fistual
- Interventions for surgical management for GERD
- Pre-op teaching, NG purpose and care, wound care and assessment, slow advancement of diet, small frequent meals, early ambulation, avoid carbonated berverages and using straw, report dysphagia, epigastric fullness, bloating, excessive borborygmus (gas-bloat-syndrome)
- Esophagomyotomy (Heller's procedure)
- enlarging the sphincter; may need PEG or PEJ short term
- Diagnostics for diverticula
- barium swallow, endoscopy may be contraindicated due to risk of perforation
- Diagnosis for esophageal neoplasms
- barium swallow, endoscopy, biopsy, CT
- Types of Antacids
- Aluminum containing (amphojel)- constipation, Calcium contaiming (TUMS)- systemic, Magnesium containing (MOM)- laxitive, Aluminum/Magnesium combo (Maalox, Mylanta)
- Interventions
- nutritional support 2-3 wks prior to surgery, monitor wt, fluid and electrolyte status, pre-op teaching, oral caare QID, post-op respiratory care: C & DB, pain management, assess shock, wound assessment, PO when indicated, small frequent meals, upright at meals and 1 hr PC, appropriate referrals
- Nissen Fundoplication
- most frequently used surgery, abdominal approach to suture the fundus around the esophagus, increase in pressure or volume in stomach closes the cardia and blocks reflux into the esophagus
- Barium swallow
- shows nonpropulsive waves and esophageal dilation
- Types of PPI
- end in "prazole", Lansoprazole (prevacid), omeprazole (prilosec), Rabeprazole (aciphex), Pantoprazole (protonix)
- Cardiovascular dysphagia
- enlarged heart, aortic aneurysm
- Gastroesophageal reflux disease (GERD)
- syndrome resulting from backward flow of gastric contents into esophagus, occurs in any age grp, inappropriate relaxation of the LES, allowing reflux, cause unkown, pain usually occurs after meals and is relieved with antacids or fluids
- Nursing DX
- risk for altered respiratory function, acute pain, risk for FVD or FVE, risk for injury, PC's: electrolyte abnormality, atelectasis, DVT, paralytic ileus, infection
- Medical management for esophageal neoplasms
- if found early then cure, but usually detected in late stages when tx is palliative, RT reduces tumor size and slows growth; may cause stenosis of esophagus, chemo provides a symptom relief, nutritional management may require enteral feeding or TPN, elevate HOB 30 degrees
- Surgical Management for esophageal neoplasms
- Esophagectomy, esophagogastrostomy, esophageoenterostomy
- Sliding hernias type I
- upper stomach and the gastroesophageal junction are displaced upward into the thorax, c/o heartburn 30-60 mins after meals
- Types of histamine receptor antagonists
- End in "tidine", Cimetidine (Tagamet), Famotidine (Pepcid), Nizatidine (Axid), Ranitidine (Zantac)
- Prostaglandin Analog
- inhibit the sexretion of gastric acid, used with NSAID, Misoprostol (cytotec)
- Causes of diverticula
- esophageal weakness from congenital defect, esophageal trauma, scar tissue or inflammation
- S/S of diverticula
- dysphagia, eructation, regurgitation of undigested food, halitosis, sour taste in mouth, coughing, bad breath
- Regurgitation
- ejection of small amounts of gastric juice from mouth without antecedent nausea, usually caused by incompetent lower esophageal sphincter (LES)
- Medical management for esophageal disorders
- relieve clinical manifestations, Ca+ channel blockers or nitrate to reduce LES pressure, pain controlled with non-narcotic and narcotic analgesics, small frequent meals, avoid hot, spicy, iced foods, alcohol, tobacco, chew foods thoroughly, sleep with HOB elevated
- Causes of hiatal hernia
- aging, congenital muscle weakness, trauma, surgery, obesity, pregnancy, ascites
- Hiatal hernia
- condtion in which the cardiac sphincter becomes enlarged, allowing a part of the stomach to oass into the thoracic cavity, r/t muscle weakness in the esophageal hiatus
- Hiatal hernia management
- medical and surgical same as GERD
- Cholinergic
- increase LES pressure and prevents reflux, Take AC, Bethanechol (Urecholine)
- Esophagoenterostomy (colon interpostion)
- resectioning the esophagus and replacing it with a segment of the descending colon, helps prevent GERD
- Medical management for diverticula
- small frequent meals of semisoft foods, elevate HOB for 2 hrs PC, avoid constrictive clothes and vigorous exercise PC
- Neurologic dysphagia
- CVA, MS
- Proton Pump Inhibitor
- supresses gastric acid secretion, may increase bleeding incidence in pts on warfarin (coumadin), may interfere with absorption of ampicillin and digoxin
- Prokinetic agents
- increase LES tone, improves esophageal peristalsis, increase rate of gastric emptying, taken ACHS, Metoclopramide (Reglan)
- ND: knowledge deficit for GERD
- teaching of diet, meds, evaluate tx understanding, ID life-style changes to reduce risk factors
- Interventions for esophageal surgies
- teaching for specific procedure, possible thoractomy approach for esophagomyotomy, PEG/PEJ instructions, sleep with HOB up, S/S respiratory complications, infection, esophageal perforation
- Diagnostics for GERD
- barium swallow, esophagoscopy, esophageal biopsy, analysis of gastric secretions, acid perfusion tests
- nursing dx for esophageal neoplasms
- risk for altered respiratory function, acute pain, risk for FVE or FVD, altered nutritional status: less than, altered coping