I. Gastroesophageal Reflux Disease (GERD)
A. Definition and Pathophysiology
● Definition: A syndrome (not a disease) where stomach acid refluxes into the
lower esophagus, causing mucosal damage.
● Primary Cause: Incompetent Lower Esophageal Sphincter (LES).
○ Normally acts as an antireflux barrier.
○ Incompetence allows gastric contents (HCl acid, pepsin, bile) to enter the
esophagus when supine or during increased intraabdominal pressure.
● Risk Factors:
○ Obesity (increases intraabdominal pressure).
○ Cigarette and cigar smoking.
○ Hiatal hernia.
○ Foods/Drugs that Decrease LES Pressure: Alcohol, chocolate, fatty
foods, nicotine, peppermint, caffeine, anticholinergics, nitrates, and calcium
channel blockers.
B. Clinical Manifestations
● Heartburn (Pyrosis): Most common; burning, tight sensation under the
sternum spreading to the throat/jaw.
● Chest Pain: Can mimic angina; burning/squeezing radiating to back, neck, or
arms (relieved by antacids).
● Dyspepsia: Pain/discomfort in the upper abdomen.
● Regurgitation: Hot, bitter, or sour liquid coming into the mouth.
● Respiratory Symptoms: Wheezing, coughing, dyspnea, hoarseness, or a
"globus sensation" (lump in throat).
C. Complications
● Esophagitis: Inflammation that can lead to scar tissue, stricture, and
dysphagia (difficulty swallowing).
● Barrett’s Esophagus (BE): Esophageal metaplasia where squamous cells
change to columnar epithelial cells. Precancerous; requires regular
surveillance.
● Respiratory: Aspiration pneumonia, bronchospasm, and dental erosion
(posterior teeth).
D. Management
● Lifestyle Modifications:
○ Elevate Head of Bed (HOB) to 30 degrees (using blocks or pillows).
○ Do not lie down for 2–3 hours after eating.
○ Avoid trigger foods (fatty foods, chocolate, peppermint, caffeine).
● Drug Therapy:
○ Proton Pump Inhibitors (PPIs): (e.g., omeprazole, pantoprazole). Most
, effective for healing esophagitis. Side effect: Long-term use increases
fracture risk.
○ H2-Receptor Blockers: (e.g., famotidine). Reduces symptoms and
promotes healing.
○ Antacids: Quick, short-lived relief; take 1–3 hours after meals.
● Surgical Therapy: Nissen or Toupet fundoplication (wrapping the stomach
fundus around the esophagus).
II. Hiatal Hernia
A. Definition and Types
● Definition: Protrusion of the stomach into the esophagus through a
diaphragmatic opening.
● Sliding Hernia: Most common; stomach slides through when supine and goes
back when upright.
● Paraesophageal (Rolling) Hernia: The fundus rolls up through the
diaphragm, forming a pocket. Acute rolling hernia is a medical emergency.
B. Etiology and Manifestations
● Causes: Weakened diaphragm muscles (aging) and increased intraabdominal
pressure (obesity, pregnancy, heavy lifting).
● Symptoms: Similar to GERD (heartburn, dyspepsia).
● Complications: Hemorrhage, stenosis, strangulation of the hernia, and
tracheal aspiration.
III. Esophageal Cancer
A. Pathophysiology
● Types: Adenocarcinoma (arises from glands, linked to BE/obesity) and
Squamous cell (linked to smoking/alcohol).
● Metastasis: Often spreads via the lymph system to the liver and lungs. High
mortality rate due to late diagnosis.
B. Clinical Manifestations
● Progressive Dysphagia: Most common symptom; starts with meat, then soft
foods, then liquids.
● Pain: Occurs late; substernal, epigastric, or back area. Increases with
swallowing.
● Weight Loss: Significant and common.
● Regurgitation: Blood-flecked contents if stenosis is severe.
C. Nursing and Interprofessional Care
● Diagnostic Gold Standard: Endoscopy with biopsy.
● Surgical Procedures:
A. Definition and Pathophysiology
● Definition: A syndrome (not a disease) where stomach acid refluxes into the
lower esophagus, causing mucosal damage.
● Primary Cause: Incompetent Lower Esophageal Sphincter (LES).
○ Normally acts as an antireflux barrier.
○ Incompetence allows gastric contents (HCl acid, pepsin, bile) to enter the
esophagus when supine or during increased intraabdominal pressure.
● Risk Factors:
○ Obesity (increases intraabdominal pressure).
○ Cigarette and cigar smoking.
○ Hiatal hernia.
○ Foods/Drugs that Decrease LES Pressure: Alcohol, chocolate, fatty
foods, nicotine, peppermint, caffeine, anticholinergics, nitrates, and calcium
channel blockers.
B. Clinical Manifestations
● Heartburn (Pyrosis): Most common; burning, tight sensation under the
sternum spreading to the throat/jaw.
● Chest Pain: Can mimic angina; burning/squeezing radiating to back, neck, or
arms (relieved by antacids).
● Dyspepsia: Pain/discomfort in the upper abdomen.
● Regurgitation: Hot, bitter, or sour liquid coming into the mouth.
● Respiratory Symptoms: Wheezing, coughing, dyspnea, hoarseness, or a
"globus sensation" (lump in throat).
C. Complications
● Esophagitis: Inflammation that can lead to scar tissue, stricture, and
dysphagia (difficulty swallowing).
● Barrett’s Esophagus (BE): Esophageal metaplasia where squamous cells
change to columnar epithelial cells. Precancerous; requires regular
surveillance.
● Respiratory: Aspiration pneumonia, bronchospasm, and dental erosion
(posterior teeth).
D. Management
● Lifestyle Modifications:
○ Elevate Head of Bed (HOB) to 30 degrees (using blocks or pillows).
○ Do not lie down for 2–3 hours after eating.
○ Avoid trigger foods (fatty foods, chocolate, peppermint, caffeine).
● Drug Therapy:
○ Proton Pump Inhibitors (PPIs): (e.g., omeprazole, pantoprazole). Most
, effective for healing esophagitis. Side effect: Long-term use increases
fracture risk.
○ H2-Receptor Blockers: (e.g., famotidine). Reduces symptoms and
promotes healing.
○ Antacids: Quick, short-lived relief; take 1–3 hours after meals.
● Surgical Therapy: Nissen or Toupet fundoplication (wrapping the stomach
fundus around the esophagus).
II. Hiatal Hernia
A. Definition and Types
● Definition: Protrusion of the stomach into the esophagus through a
diaphragmatic opening.
● Sliding Hernia: Most common; stomach slides through when supine and goes
back when upright.
● Paraesophageal (Rolling) Hernia: The fundus rolls up through the
diaphragm, forming a pocket. Acute rolling hernia is a medical emergency.
B. Etiology and Manifestations
● Causes: Weakened diaphragm muscles (aging) and increased intraabdominal
pressure (obesity, pregnancy, heavy lifting).
● Symptoms: Similar to GERD (heartburn, dyspepsia).
● Complications: Hemorrhage, stenosis, strangulation of the hernia, and
tracheal aspiration.
III. Esophageal Cancer
A. Pathophysiology
● Types: Adenocarcinoma (arises from glands, linked to BE/obesity) and
Squamous cell (linked to smoking/alcohol).
● Metastasis: Often spreads via the lymph system to the liver and lungs. High
mortality rate due to late diagnosis.
B. Clinical Manifestations
● Progressive Dysphagia: Most common symptom; starts with meat, then soft
foods, then liquids.
● Pain: Occurs late; substernal, epigastric, or back area. Increases with
swallowing.
● Weight Loss: Significant and common.
● Regurgitation: Blood-flecked contents if stenosis is severe.
C. Nursing and Interprofessional Care
● Diagnostic Gold Standard: Endoscopy with biopsy.
● Surgical Procedures:
