Textbook Discussion

I.

Definition Gastroesophageal reflux (chalasia, cardiochalasia) is the return of gastric contents into the esophagus and possibly the pharynx. It is caused by dysfunction of the cardiac sphincter at the esophagus-stomach juncture. Reasons for this incompetence include an increase of pressure on the lower esophageal sphincter; following esophageal surgery; or immature lower esophageal neuromuscular function. The result of the persistent reflux is inflammation, esophagitis, and bleeding causing possible anemia and damage to the structure of the esophagus as scarring occurs. It also may predispose to aspiration of stomach contents causing aspiration pneumonia and chronic pulmonary conditions. Most commonly affected are infants and young children. As the condition becomes more severe or does not respond to medical treatment and the child experiences failure to thrive, surgical fundoplication to create a valve mechanism or other procedures may be done to correct the condition. The lower esophageal sphincter regulates the flow of food from the esophagus into the stomach. Both internal and external mechanisms function in maintaining the antireflux function of the lower esophageal sphincter. Relaxation of the lower esophageal sphincter is a brain stem reflex that is mediated by the vagus nerve in response to a number of afferent stimuli. Transient relaxation with reflux is common after meals. Gastric distension and meals high in fat increase the frequency of relaxation. Refluxed material normally is returned to the stomach by secondary peristaltic waves in the esophagus, with swallowed saliva neutralizing and washing away the refluxed acid. GERD is thought to be associated with a weak or incompetent lower esophageal sphincter that allows reflux to occur the irritant effects of the refluxate, and decreased clearance of the refluxed acid from the esophagus after it has occurred. Delayed gastric emptying also may contribute to reflux by increasing gastric volume and pressure with greater chance for reflux. Esophageal mucosal injury is related to the destructive nature of the refluxate and the amount of time it is continue to have daytime symptoms, recurrent strictures, or large esophageal ulcerations. Surgical treatment may be indicated in some people

Signs and Symptoms Signs and Symptoms found in textbook Heart burn Vomiting Hiatal Hernia Weight loss Signs and Symptoms manifested by the client As verbalize by patient every time after eating 19 days PTC(Sept 9 2012), every after meals (-) Patient lost 4 kg from previous weight which is 28 kg (-) (-) (-) (-) (-) (-) First symptom manifested by the patient. Sept 9, 2012

Mucosal injury of esophagus Wheezing Chronic cough Aspiration Laryngeal injury Bronchospasm Fever

Management Nursing Management Avoidance of positions and conditions that increase gastric reflux positions such as supine position, trendelenburg postion, or any postion that the head is lower than the body. Avoidance of large meals and foods that reduce lower esophageal sphincter tone (e.g., caffeine, fats, chocolate), alcohol, and smoking is recommended. Sleeping with the head elevated helps to prevent reflux during the night. If vomiting procedure occurs, assess vomiting, activity and position client every after feeding.

Medical Management Administration of Proton Pump Inhibitors: lansoprazole (Previcid) or omeprazole (Prilosec) to suppress gastric acid secretion. Administration of H2 Receptor Antagonists: cimetidine (Tagamet), or ranitidine (Zantac) to reduce gastric acidity and pepsin secretion. Barium Esophagram to reveals reflux of barium into the esophagus under fluoroscopy if done at time reflux occurs. Manometry to reveal esophageal sphincter pressure of less than 6 mm Hg. Intraesophageal pH Monitoring to reveal pH measurements of the distal esophagus reflux contents. Gastroesophageal Scintigraphy to reveal reflux or aspiration following ingestion of a radioactive compound and scanning the esophagus. Gastroscopy an endoscopic examination that reveals view of esophagus to note esophagitis or to remove tissue for biopsy. Complete Blood Count to reveal decreased RBC, Hgb, Hct in persistent blood loss.

Surgical Management If medical management is unsuccessful, surgical intervention may be necessary. Surgical management involves a fundoplication (wrapping of a portion of the gastric fundus around the sphincter area of the esophagus)