Chapter 45- Esophageal PDF

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Chapter 45: Patients with Oral and Esophageal Disorders: Disorders of the Esophagus: - Disorders of the esophagus include motility disorders (Achalasia, spasms), hiatial hernias, diverticular, perforation, foreign bodies, chemical burns, GERD, Barrett esophagus (BE), benign tumors, and carcinoma - Dysphagia, the most common symptom of esophageal disease, may vary from: o An uncomfortable feeling that a bolus of food is caught in the upper esophagus o To acute odynophagia: Pain on swallowing - Achalasia: o Absent or ineffective peristalsis of the distal esophagus accompanied by failure of the esophageal sphincter to relax in response to swallowing o Clinical Manifestations: Dysphagia (solids and liquids)  Patient may also report non-cardiac chest or epigastric pain and pyrosis (heartburn) that may or may not be associated with eating o Assessment and Diagnostic Findings  XR studies show esophageal dilation above the narrowing at the gastroesophageal junction  Barium swallow, CT scan of the chest, and endoscopy may be used for diagnosis  Manometry o Management:  Eat slowly and drink fluids with meals -

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Esophageal Spasm: o Two types:  Diffuse Esophageal Spasm (DES):  Spasms are normal in amplitude  But are uncoordinated, move quickly, or occur at various places in the esophagus at once  Hypertensive Peristalsis aka Nutcracker Esophagus (NE)  Peristalsis is coordinated, but the amplitude is very high  Hypercontactile esophagus: aka Jackhammer Esophagus o An extreme of NE in which the contractions involve the entire esophagus and over a prolonged period  Clinical Manifestations:  Characterized by dysphagia, odynophagia, and chest pain similar to that of coronary artery spasm  Assessment and Diagnostic Findings:  Esophageal Manometry, which measures the motility and internal pressure of the esophagus, can test for irregular and high-amplitude spasms  Management:  Conservative, first line therapy: Calcium channel blockers  Smooth muscle relaxants, antianxiety medications, and proton pump inhibitors may also be indicated  Small, frequent feedings and a soft diet are usually recommended to decrease the esophageal pressure and irritation that lead to spasm Hiatal Hernia: o The opening in the diaphragm through which the esophagus passes becomes enlarged, and part of the upper stomach moves up into the lower portion of the thorax o Two main types:  Sliding aka Type I: Occurs when the upper stomach and the gastroesophageal junction are displaced upward and slide in and out of the thorax

Paraesophageal: Occurs when all or part of the stomach pushes through the diaphragm beside the esophagus  Classified as types II, III, IV, depending on the extent of herniation  Type IV has the greatest herniation, with other intra-abdominal viscera such as the coon, spleen, or small bowel evidencing displacement into the chest along with the stomach Clinical Manifestations:  Sliding: Pyrosis (heartburn), regurgitation, dysphagia  Many patients are asymptomatic  Patient may present with vague symptoms of intermittent epigastric pain or fullness after eating  Large hiatal hernias may lead to intolerance of food, N/V  Commonly associated with GERD  Hemorrhage, obstruction, and strangulation can occur with any type of hernia Assessment and Diagnostic Findings:  Typically confirmed with XR studies; barium swallow, Esophagogastroduodenoscopy (EGD), which is the passage of a fiber-optic tube through the mouth and throat into the digestive tract for visualization of the esophagus, stomach, and small intestine; esophageal manometry, or chest CT scan Management:  Includes frequent, small feedings that can pass easily through the esophagus  Patient is advised not to recline for 1 hour after eating, to prevent reflux or movement of the hernia  Elevate HOB on 4- to 8- in blocks to prevent hernia from sliding upward 

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Diverticulum: o An esophageal diverticulum is an out-pouching of mucosa and submucosa that protrudes through a weak portion of the musculature of the esophagus o May occur in one of three areas of the esophagus:  Pharyngoesophageal (Upper)  Midesophageal (middle)  Epiphrenic (Lower) o Most common type: Zenker diverticulum  Located in pharyngoesophageal area  Caused by a dysfunctional sphincter that fails to open, which leads to increased pressure that forces the mucosa and submucosa to herniate through the esophageal musculature (called a pulsion diverticulum) o Midesophageal diverticula: Uncommon  Less acute symptoms  Usually does not require surgery o Epiphernic: Usually larger diverticula in the lower esophagus just above the diaphragm  May be related to improper functioning of the lower esophageal sphincter or to motor disorders o the esophagus o Intramural diverticulosis: The occurrence of numerous small diverticular associated with a stricture in the upper esophagus o Clinical Manifestations:  Dysphagia, fullness in the neck, belching, regurgitation of undigested food, and gurgling noises after eating  The diverticulum, or pouch, becomes filled with food or liquid  Halitosis and a sour taste in the mouth are common because of the decomposition of food retained in the diverticulum

Assessment and Diagnostic Findings:  Barium swallow may determine exact nature and location of a diverticulum  Manometric studies  Esophagoscopy o Management:  Because Zenker diverticulum is progressive, the only means of cure is surgical removal of the diverticulum Perforation: o Surgical emergency o May result from iatrogenic causes, such as endoscopy or intraoperative injury, or from spontaneous perforation associated with forceful vomiting or severe straining (Boerhaave syndrome), foreign-body ingestion, trauma, and malignancy o Clinical Manifestations:  Excruciating retrosternal pain followed by dysphagia  Infection, fever, leukocytosis, and severe hypotension may be noted  Mediastinal sepsis can occur, accompanied by pneumothorax and subcutaneous emphysema o Assessment and Diagnostic Findings:  XR studies, fluoroscopy by either a barium swallow or esophagram (non-invasive), or CT chest scan o Management:  Esophageal perforation requires immediate treatment  NPO, begin IV fluid therapy, administer broad-spectrum antibiotics  Supportive monitoring and care (ICU)  Evaluating and preparing patient for surgery o

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Foreign Bodies: o Many swallowed foreign bodies need medical intervention o Some swallowed foreign bodies (ie: Dentures, fish bones, pins, small batteries, items containing mercury or lead) may injure the esophagus or obstruct its lumen and must be removed o Pain and dysphagia may be present, dyspnea may occur as a result of pressure on the trachea o May be identified through XR o Glucagon may be injected IV o Flexible endoscope and retrieval devices may be used to remove impacted food or object

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Chemical Burns: o Most often occur when a patient intentionally or unintentionally swallows a strong acid or base, with alkaline agents being the most common o Patient is often emotionally distraught as well as in acute physical pain o May also be caused by undissolved medications in the esophagus o Or after swallowing a battery, which may release a caustic alkaline o Acute chemical burn may be accompanied by severe burns of the lips, mouth, and pharynx, with pain on swallowing o Breathing difficulties due to either edema of the throat or a collection of mucus in the pharynx may occur o Patient is treated immediately for shock, pain, and respiratory distress o Esophagoscopy, barium swallow o Nutritional support via enteral or parenteral feedings o Surgical intervention may be necessary if medical management is unsuccessful

TABLE452 Phar macol ogi cManagementofGERD KeyExampl es

Act i ons/ Cl ass

KeyNur si ngConsi der at i ons

Antacids/Acid neutralizing agents • Calcium carbonate (Tums) • Aluminum hydroxide, magnesium, hydroxide, and simethicone (Maalox)

Neutralize acid Therapeutic and Pharmacologic class—Antacid

• Potential risk of gastric acid suppression i protective flora and an increased risk especially Clostridium difficile

Histamine-2 (H2) receptor antagonists • Famotidine (Pepcid) • Ranitidine (Zantac) • Cimetidine (Tagamet)

Decrease gastric acid production Therapeutic class— Antiulcer drugs Pharmacologic class— H2-receptor antagonists

• Potential risk of gastric acid suppression is protective flora and an increased risk especially Clostridium difficile • For direct injection (IVP), dilute 2 mL ( compatible solution to a total volume 10 mL; administer over at least 2 minu • Monitor for QT-interval prolongation in pa kidney injury

Prokinetic agents Metoclopramide (Reglan)

Accelerate gastric emptying Therapeutic class—GI stimulants Pharmacologic class— Dopamine antagonist

• May cause tardive dyskinesia • Typically used short term

Proton pump inhibitors (PPIs) • Pantoprazole (Protonix) • Omeprazole (Prilosec) • Esomeprazole (Nexium) • Lansoprazole (Prevacid) • Rabeprazole (AcipHex) • Dexlansoprazole (Dexilant)

Decrease gastric acid production Therapeutic class— Antiulcer drugs Pharmacologic class— Proton pump inhibitors

• Potential risk of gastric acid suppression i protective flora and an increased risk especially Clostridium difficile • For a 2-minute infusion (IVP), give the recon (4 mg/mL) over at least 2 minutes • May increase the risk of hip fractures and some vitamin and mineral absorptio magnesium) • Interact with commonly prescribed medica diuretics and clopidogrel

Reflux inhibitors Bethanechol chloride (Urecholine)

Stimulates parasympatheti c Therapeutic and Pharmacologic class—Cholinergic

• Primary use is for urinary retention • Do not use with possible GI obstruction or pe

Sur f aceAgent s/ Al gi nat ebased bar r i er s • Sucralfate

Pr eser vemucosal bar r i er Therapeutic class— Antiulcer drugs Pharmacologic class-– GI protectants

• Give on an empty stomach hour before or meals • Separate from doses of antacid by 30 minute

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GERD:

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Marked by backflow of gastric or duodenal contents into the esophagus that causes troublesome symptoms and/or mucosal injury to the esophagus Excessive reflux may occur because of an incompetent lower esophageal sphincter, pyloric stenosis, hiatal hernia, or a motility disorder Incidence increases with age and is seen in patients with irritable bowel syndrome and obstructive airway disorders Clinical Manifestation:  Pyrosis, dyspepsia (indigestion), regurgitation, dysphagia, or odynophagia, hypersalivation, and esophagitis Assessment and Diagnostic Findings:  History aids in obtaining accurate diagnosis  Endoscopy or barium swallow  pH monitoring Management:  Educate patient to avoid situations that decrease lower esophageal sphincter pressure or cause esophageal irritation  Low-fat diet, avoid caffeine, tobacco, beer, milk, foods containing peppermint or spearmint, and carbonated beverages; avoid eating or drinking 2 hours before bed; maintain normal body weight, avoid tight-fitting clothes, elevated HOB 30 deg

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Barrett Esophagus: o Condition in which the lining of the esophageal mucosa is altered o Reflux eventually causes changes in the cells lining the lower esophagus o Clinical Manifestations:  Symptoms of GERD, frequent heartburn  Symptoms related to peptic ulcers or esophageal stricture or both o Assessment and Diagnostic Findings:  EGD, biopsies, high grade dysplasia (HGD; abnormal changes in cells) is evidenced by the squamous mucosa of esophagus replaced by columnar epithelium that resembles that of the stomach or intestines o Management:  Monitoring varies on depending on the extent of cell changes  Follow up biopsies are recommended no sooner than 3-5 years after a biopsy shows no evidence of dysplasia

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Benign Tumors of the Esophagus: o Rare but can arise anywhere along the esophagus o Most common lesion: Leiomyoma (tumor of smooth muscle)  Can occlude the lumen of the esophagus and cause dysphagia, pain, and pyrosis o Nursing Process:  Assessment: Infections, chemical, mechanical, physical irritants, alcohol/tobacco use, daily food intake  Nursing Diagnosis:  Imbalanced nutrition: Less than body requirements related to difficulty swallowing  Risk for aspiration related to difficulty swallowing or 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, med management, surgical intervention, rehabilitation  Planning and Goals:

Attainment of adequate nutritional intake, avoidance of respiratory compromise from aspiration, relief of pain, and increased knowledge level Nursing Interventions:  Encouraging adequate nutritional intake  Decreasing risk of aspiration  Relieving pain 

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