Gastro esophageal reflux disease

(case study)
Introduction
Some degree of gastroesophageal reflux (backflow 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.
Reflux refers to the stomach acid rising up the wrong way up to the esophagus and sometimes
into the mouth. In this occurs chronically it is probably cause by GERD. Symptoms physically
include frequent heartburn, reflux and regurgitation but may also include chest pain hoarseness
and difficulty in swallowing. If the symptoms mimic those of heart attack, further assessment
and reviewing the patient history will aid to obtain the accurate diagnosis.

Significance of the study

This case study will help the group in understanding the disease process of the client. This
would also help the group in identifying the primary needs of the patient with GERD. By
identifying such needs and health problems arise the group can now formulate an individualized
nursing care plan for the patient that would address these needs and problems effectively.
Effective management of the problems identified will help the patient to recover faster and
maintain a holistic sense of wellness seen while he is in the hospital.
This case study would also equip the group with knowledge, skills and attitude on how to
manage future patients with the same or similar disease.

Patients Profile
Few days prior to admission, a 91 year old male client Theodoro Bucasio experiences cough
with no medication taken, after a few hours the client experienced a sudden onset of abdominal
pain going to the chest area thus he was brought at the hospital.
Upon interview, the patient was asked about past health history. He told us that he had
undergone colecystectomy in the year 2006. He was admitted in Urdaneta Sacred Heart
Hospital but the operation took place at Region I Medical Center. He was a non smoker but
heavily drinks alcoholic beverages during his childhood years.
His physical examination reveals a regular cardiac rhythm, with rales and negative heart
murmurs. Upon palpation of the abdomen and extremities, there was a positive abdominal
tenderness and negative for edema. He was diagnosed of having GERD and was admitted to
PR1 by Dr. Ancheta.

Laboratory history
Chest x-ray
Streaky densities are seen in the left basal area
Heart is slightly enlarged
Aorta is tortuous
Pulmonary vascularity is within normal
Diaphragm, costophrenic sulci and osseous structure are intact
Impression:
Pneumonitis, left basal area
Mild cardiomegaly
Atheromatous aorta
Fecalysis
Color: brown
Consistency: soft
Pus cells: none
Red cells: none
Impression:Negative for any parasitic cyst or ova

Clinical chemistry:
Normal values:

Glucose (FBS): 178 mg/dl 70-100 mg/dl

Cholesterol: 77.8 mg/dl 150-200 mg/dl
Triglycerides: 38.0 mg/dl 35-150 mg/dl
HDL: 30.0 mg/dl 30-85 mg/dl
LDL: 40.0 mg/dl 50-175 mg/dl
BUN: 13.2 8.0-23.0
Creatinine: 0.6 0.5-1.7
Na: 143.0 134-148
K: 4.17 3.6-5.4
Cl: 13.7 98-107

Clinical microscopy:
Urinalysis
Color: yellow

Specific gravity: 1.010

Character: turbid
Protein: +1
pH: 6.0
Sugar: negative
Pus cells: TNTC/hpf
RBC: 3.5
Epithelial cells: moderate
Amosphous urates: many
Mucus threads: many
Bacteria: many

Hematology

Erythrocyte: 5.37
Leukocytes: 10.9
Hemoglobin: 112g/L
Hematocrit: 0.35
Leukocyte type
Segmenters: 0.84
Lymphocyte: 0.13
Monocyte: 0.03
Thrombocyte sedimentation rate: 152

ECG

PQ: 268ms
QRS: 80ms
QTC: 508ns
ST: 0.73mv
HR: 77bpm
RR: 776ms

Anatomy and Physiology

The esophagus is a muscular tube, usually between 10 and 13 inches long, that runs through
the neck and upper chest connecting the mouth to the stomach. Through a process called
peristalsis (involuntary wave-like muscular contractions), the esophagus moves food and liquids
from the mouth to the stomach, where they are digested and broken down before passing into
the intestines.
The esophagus is lined with a special mucous membrane that protects it from the constant
passage of food. This membrane is made up of flat, thin cells, known as squamous cells.
At the bottom of the esophagus, the lower esophageal sphincter – a ring-like muscle that
serves as a one-way valve – allows food to pass into the stomach while preventing chime (a
mixture of food, stomach acid, and digestive enzymes) from traveling back up the esophagus.
When the sphincter becomes weak or fails completely, acidic chyme is no longer prevented
from entering the esophagus, which can cause a painful and potentially dangerous condition
known as gastro esophageal reflux disease (GERD). Over time, GERD can lead to a pre-
cancerous condition called Barrett’s Esophagus.
Pathophysiology
Gastro esophageal reflux disease, also known as GERD is caused by your esophagus becoming
agitated by substances coming up from your stomach, including stomach acid. This backing up
process of stomach substances is known as reflux. Your esophagus is essentially a tube that
connects you throat to your stomach. Your stomach produces hydrochloric acid which helps in
digesting your food. The inner lining of the stomach is protected from the acid by mucus which
is secreted by the stomach. The pathophysiology of GERD indicates that the inner lining of your
esophagus does not have the protection that is found in the stomach and therefore the acid can
cause harm to your esophagus. 

When the reflux occurs you feel a burning feeling in your esophagus, however most people call
this sensation heartburn due to the esophagus being located behind your heart. For most
people the muscle ring located at the bottom of the esophagus known as the lower esophageal
sphincter stops the backing up of acid into your esophagus. If it is functioning properly it
loosens up in order to allow food to pass down to your stomach and then tightens up in order
to prevent reflux from occurring. The pathophysiology of GERD indicates that people who have
GERD have a condition where the lower esophageal sphincter loosens up between swallows of
food which allows the stomach acid to travel up into your esophagus and create a burning
sensation.

Diagnostic Test
Upper Endoscopy/ Esophagogastroduodenoscopy (EGD)
The upper endoscopy (also known as esophagogastroduodenoscopy or EGD) allows the doctor
to examine the inside of the patient's esophagus, stomach, and duodenum (the first part of the
small intestine) with an instrument called an endoscope, a thin flexible lighted tube.
During the endoscopy exam, the doctor will be able to see the walls and tissue of the upper
digestive tract, and will be able to detect disorders such as strictures (narrowed areas), hiatal
hernias, ulcers and tumors. If necessary, biopsies can be collected
•The patient is not to eat anything for at least six hours before the procedure.
•A local anesthetic will be sprayed into the patient's throat to suppress the gag reflex, and an
intravenous sedative will help the patient relax.
•The endoscope is then slowly passed into the patient's mouth and down the esophagus. The
gag reflex and the urge to vomit usually pass once the tube is in the esophagus. The tube will
not interfere with breathing.
•Once the endoscope is in place, the doctor will be able to examine the esophagus and stomach
through a tiny camera, and detect any abnormalities. Other instruments can be inserted
through the endoscope tube, which will allow the doctor to perform biopsies if such conditions
as cancer or infections are evident.
•The patient may experience a sore throat for a few days after the procedure. This is common.
If complications (such as vomiting a large amount of blood or severe stomach pains) occur, the
doctor should be notified immediately.
Barium Swallow/ Barium X-ray/ UGIS
Barium x-rays, also known as barium swallow, are diagnostic x-rays in which barium is used to
diagnose abnormalities of the digestive tract. The patient drinks a chalky colored liquid that
contains barium. It coats the walls of the esophagus and stomach, and is visible on x-rays. A
person reading the x-ray can then see if there are strictures, ulcers, hiatal hernias, erosions or
other abnormalities.
This test is not sensitive enough to be used as a reliable diagnostic test for GERD. It is used
more often in patients who are experiencing difficulty with swallowing. 
•The patient is asked not to eat or drink anything after midnight on the night before the exam.
•The patient stands against an upright x-ray table in front of a fluoroscope, a device that will
immediately show a moving picture. The patient then drinks the barium liquid and swallows
baking soda crystals. The radiologist can watch the barium flow through the digestive tract. The
patient may be asked to move into different positions while the x-rays are taken so the doctor
can observe the barium from different angles as it travels down the esophagus and into the
stomach.
•Since barium may cause constipation, the patient is advised to drink plenty of fluids and eat
high-fiber foods for the next day or two until the barium passes from the body.
pH Test
The pH procedure is done with a thin, plastic tube with a sensor that measures the amount of
acid backing up into the esophagus. This procedure is often done when GERD symptoms are
present but an endoscope exam doesn't detect any evidence of reflux disease.
The pH test measures how often and for how long stomach acid enters the esophagus, and
how well it clears the esophagus.
•The doctor inserts a tubular probe through the nose and into the esophagus. The tube stops
just above the lower esophageal sphincter (LES). This can also be performed during endoscopy
by clipping a pH monitoring device to the lining of the esophagus.
•The tube is left in place for 24 hours. The patient is encouraged to engage in normal activities.
•The patient keeps a record of any symptoms that are suspected to be acid reflux. The patient
also will record other symptoms, such as coughing and wheezing. This can help the doctor
determine if acid reflux is related to unexplained asthmatic or other respiratory symptoms.

Nursing Management:
Management begins with teaching the client 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 6-8inches or 15-
20cm blocks; and to elevate the upper body on pillows.

Medical Management:
Antacids or H2 receptor antagonists, such as famotidine (Pepcid), nizatidine (Axid), or ranitidine
(Zantac), may be prescribed. Proton pump inhibitors (medications that decrease the release of
gastric acid, such as lanzoprazole [Prevacid], rabeprazole [AcipHex], esomeprazole [Nexium],
omeprazole [Prilosec], and pantoprazole [Protonix]0 may be used; however, these products
may increase gastric bacterial growth and the risk of infection. In addition, the patient may
receive prokinetic agents, which accelerates gastric emptying. This includes bethanechol
(Urecholine), domperidone (Motilium), and metoclopramide (Reglan). Because metoclopramide
can have extrapyramidal side effects that are increased in certain neuromuscular disorders,
such as Parkinson’s disease, it should only used only if no other option exists, and the patient
should be monitored closely.
Surgical Management:
The most common procedure is the laparoscopic Nissen fundoplication. An open Nissen
fundoplication was commonly used for the treatment of reflux disease with good to excellent
long term success in about 85% of patients. The extension of laparoscopic techniques to anti
reflux surgery has shown less morbidity, shorter hospital stays and less analgesic requirements.
These results have rekindled the interest in the surgical management of this disease. Five small
incisions which range in size between 5 and 12 millimeters are made in the upper abdomen. .
The operation proceeds by returning the stomach to the abdomen with gentle traction in the
case of a hiatal hernia. The phreno-esophageal ligament is taken down to allow dissection of
the esophagus at the level of the esophageal hiatus. The esophagus is completely freed of its
associated attachments. A window is created behind the esophagus through which the fundus is
eventually pulled. Once the stomach and LES is resting freely below the diaphragm, the
esophageal hiatus is repaired to a normal size. The next portion of the procedure involves
mobilizing the fundus by dividing the short gastric arteries which attach it to the spleen. This
allows for a loose wrap of the gastric fundus around the esophagus without tension. Older
procedures in which die stomach was not completely mobilized resulted in a higher incidence of
postoperative dysphagia. A two centimeter, 360 degree wrap is then performed over an
esophageal dilator. The dilator prevents wrapping the stomach too tightly around the
esophagus.