The reflux (backward flow) of stomach contents into the esophagus. This results in inflammatory changes in the esophageal mucosa: reflux esophagitis. Its causes vary, including inappropriate relaxation or decreased tone of the lower esophageal sphincter (LES), elevated gastric volume or intra-abdominal pressure, and delayed gastric emptying.
Assessment Findings
- Heartburn (Pyrosis): substernal/retrosternal burning sensation that may radiate to the neck, jaw, and back. This may sometimes mimic the pain felt in coronary artery disease or in myocardial infarctions.
- Dyspepia: indigestion
- Regurgitation: warm fluid travels up the throat with a sour or bitter taste, which also creates a risk for aspiration. Assess for crackles in the lungs.
- Dysphagia (difficulty) and Odynophagia (pain)
- Water Brash: excessive production of saliva (hypersalivation) mixes with stomach acid, and is then refluxed. This is different with regurgitation as it does not involve undigested food.
- Esophagitis and Barrett’s Epithelium/Barrett’s Esophagus: abnormal conversion of normally squamous epithelia to columnar epithelia. This is a result of the inflammatory healing process attempting to become more acid-resistant.
- These cells can become considered as pre-malignant for patients with prolonged GERD.
- Other manifestations:
- Chronic cough (especially nocturnal d/t positioning) from micro-aspiration/aspiration of refluxed gastric contents.
- Asthma either due to aspiration or from neurogenic induction of inflammation.
- Introduction of gas (secondary): eructation (belching), flatulence (farting), and bloating.
- Nausea and Vomiting
Diagnostic Examination
- Most Reliable: (12 to 36 hour) 24-hour Ambulatory pH Monitoring, wherein a small catheter is placed through the nose and into the distal esophagus. Continuous pH monitoring and recording is performed.
- Bilirubin Monitoring is used to measure to bile reflux patterns.
- EGD Endoscopy
- Esophageal Manometry: a form of “motility testing” where a water-filled catheter is inserted through the mouth or nose then into the distal esophagus, slowly being withdrawn as it measures the pressure created by the esophagus’ peristaltic movements. However, this is not reliable for a diagnosis of GERD.
Nursing Interventions
Diet Therapy
- Limit food that decrease LES tone e.g. fat and caffeine, peppermint, spicy, highly seasoned, irritating or acidic foods e.g. orange juice and tomatoes, alcoholic, and carbonated beverages that increase gastric pressure.
- Cease smoking
- Consume four to six small meals a day. Large meals may induce GERD due to a fuller stomach and increased acid production. Do not eat or snack in the evening or 2 to 3 hours before bed.
- Eat slowly and chew thoroughly. This will reduce belching from swallowing air.
- Remain upright for 1 to 2 hours after meals (if possible) to reduce incidence of GERD.
Lifestyle Changes
- Sleeping with a left side-lying (decubitus) position improves acid clearance and acid exposure which improve normal and nocturnal symptoms.
- Standing or sitting after meals help reduce episodes.
- Always sleep with your head elevated 8 to 12 inches as an aspiration precaution and to reduce the effects of GERD.
- Reduce weight if overweight.
- Avoid wearing constrictive clothing, and avoid heavy lifting or exercise (that increases intra-abdominal pressure)
Medical Interventions
- Proton Pump Inhibitors: the main treatment for GERD. This inhibits the proton pump of the parietal cells, which subsequently inhibits acid secretion.
- Omeprazole (Prilosec), Lansoprazole (Prevacid), Rabeprazole (AcipHex), Pantoprazole (Protonix), Esomeprazole (Nexium)
- These products may increase intragastric bacterial growth and the risk of infection.
- Antacids: these neutralize hydrochloric acid and deactivates pepsin.
- Aluminum Hydroxide, Magnesium Hydroxide, Maalox, Mylanta
- Histamine (H2) Receptor Antagonist: decreases acid production by the parietal cells.
- Famotidine (Pepcid), Ranitidine (Zantac), Cimetidine (Tagamet), Nizatidine (Axid)
- Prokinetic Agents are used for faster gastric emptying.
- Bethanechol (Urecholine), Domepridone (Motilium), Metoclopramide (Reglan)
- Metoclopramide (Reglan) should only be used as a last resort due to its extrapyramidal side effects.
Surgical Management
- If required, the gold standard for surgical treatment is a Laparascopic Nissen Fundoplication where the upper portion (fundus) of the stomach is wrapped around the lower esophagus, creating a secondary sphincter.
- Stretta Procedure (Endoscopic Therapy): a non-invasive esophageal reconstruction via an endoscope placed near the gastroesophageal junction, where therapeutic levels of energy produced via radiofrequency pulse is applied to the lower esophageal sphincter (LES), reshaping it.