GASTROESOPHAGEAL REFLUX DISEASE AND ESOPHAGITIS

Gastric contents flow back into the esophagus in gastroesophageal reflux disease (GERD) due to incompetent lower esophageal sphincter (LES). Esophagitis, or inflammation of the esophageal mucosa, may result.

Pathophysiology and Etiology

• Gastroesophageal reflux associated with an incompetent LES—gastric contents reflux (flow backward) through the LES into the esophagus.
• Can be the result of impaired gastric emptying from gastroparesis or partial gastric outlet obstruction.
• The acidity of gastric content and amount of time in contact with esophageal mucosa are related to the degree of mucosal damage.
• Inflammation and ulceration of the esophagus may result, causing esophagitis.
• May be caused by motility disorders—achalasia, scleroderma, esophageal spasm.

Clinical Manifestations

GERD

• The most common symptom is heartburn (pyrosis), typically occurring 30 to 60 minutes after meals and with reclining positions. May have complaints of spontaneous reflux (regurgitation) of sour or bitter gastric contents into the mouth.
• Other typical symptoms include globus (sensation of something in throat), mild epigastric pain, dyspepsia, and nausea and/or vomiting.
• Dysphagia is a less common symptom.
• Atypical symptoms include chest pain, hoarseness, recurrent sore throat, frequent throat clearing, chronic cough, dental enamel loss, bronchospasm (asthma/wheezing), and odynophagia (sharp substernal pain on swallowing).
• Symptoms that may suggest other disease etiologies need further evaluation: atypical chest pain (rule out possible cardiac causes), dysphagia, odynophagia, GI bleeding, shortness of breath, or weight loss (rule out cancer or esophageal stricture).

Esophagitis

• Esophagitis is an acute or chronic inflammation of the esophagus. Severity of symptoms may be unrelated to the degree of esophageal tissue damage.
• Symptoms vary according to etiology of esophagitis. Symptoms include dysphagia, odynophagia, severe burning, chest pain.
• Causes of esophagitis other than GERD
  • Infectious—Candida, herpes, human immunodeficiency virus, cytomegalovirus
  • Chemical (alkali or acid) or radiation therapy
  • Medication-induced—may include doxycycline, ascorbic acid, quinidine, potassium chloride, bisphosphonates

Diagnostic Evaluation

• Uncomplicated GERD may be diagnosed on patient history of typical symptoms.
• Endoscopy can visualize inflammation, lesions, or erosions. Biopsy can confirm diagnosis.
• Esophageal manometry measures LES pressure and determines if esophageal peristalsis is adequate. This study should be used before patients undergo surgical treatment for reflux. This test is also done before a pH probe for determination of correct catheter placement.
• Acid perfusion (Bernstein test)—onset of symptoms after ingestion of dilute hydrochloric acid and saline is considered positive. This test differentiates between cardiac and noncardiac chest pain.
• Ambulatory 24-hour pH monitoring is frequently performed for diagnosing GERD or reflux esophagitis. It determines the amount of gastroesophageal acid reflux and has a 70% to 90% specificity rate. The Bravo pH capsule system is a catheter-free system in which a capsule containing a radiotelemetry pH sensor is inserted into the esophagus. This sensor transmits signals to an external pager-size receiver, allowing the patient to be catheter-free during the 24 hours of pH testing.
• Barium esophagography—use of barium with radiographic studies to diagnose mechanical and motility disorders. This test is rarely useful in diagnosing GERD.

NURSING ALERT

The Bravo pH capsule system is contraindicated for patients with pacemakers, implantable defibrillators, or neurostimulators. It is also contraindicated for patients with a history of severe esophagitis, varices, obstructions, bleeding diatheses, or strictures.

NURSING ALERT

The patient should not undergo MRI within 30 days of Bravo capsule pH monitoring.

Management

Treatment goals include symptom elimination, healing esophageal damage (if present), and preventing complications and relapse.

Lifestyle Modifications

• Head of bed raised 6 to 8 inches (15 to 20 cm).
• Do not lie down for 3 to 4 hours after eating—time frame for greatest reflux.
• Bland diet—avoid garlic, onion, peppermint, fatty foods, chocolate, coffee (including decaffeinated), citrus juices, colas, and tomato products.
• Avoid overeating—causes LES relaxation.
• No tight-fitting clothes.
• Weight control.
• Smoking cessation.
• Reduce alcohol.

Pharmacologic Treatment

• Antacids—reduce gastric acidity. Use on an as-needed basis. Provide symptomatic relief but do not heal esophageal lesions.
• Histamine-2 (H₂) receptor antagonists, such as ranitidine (Zantac), cimetidine (Tagamet), famotidine (Pepcid), nizatidine (Axid)—decrease gastric acid secretions. Provide symptomatic relief. May require lifelong therapy.
• If symptoms do not respond to H₂-receptor antagonist, change to a once-per-day proton pump inhibitor (PPI), such as omeprazole (Prilosec), esomeprazole (Nexium), pantoprazole (Protonix), rabeprazole (Aciphex), or lansoprazole (Prevacid), to block gastric acid secretion.
• PPIs have been shown to be more effective than H₂-receptor antagonists in achieving faster healing rates for erosive esophagitis.
• Drug maintenance therapy may be needed depending on the severity of disease and recurrence of symptoms after initial drug therapy is stopped.
• Use the lowest effective drug dose of H₂-receptor blocker or proton pump inhibitor.

DRUG ALERT

OTC H₂-receptor antagonists include Axid AR, Pepcid AC, Tagamet HB, and Zantac 75. These OTC medications are half the strength of the same medications obtained through prescription.

DRUG ALERT

Patients with renal insufficiency and elderly patients may need decreased dosing of H₂ receptor antagonists.

DRUG ALERT

PPIs should be taken 30 to 60 minutes before a meal for optimal control of gastric acidity.

Antireflux Surgery

• May be indicated for patients who do not respond to medical management. Common procedure is Nissen fundoplication.
  • Upper portion of the stomach is wrapped around the distal esophagus and sutured, creating a tight LES.
  • This procedure can be performed laparoscopically.
  • Combined with vagotomy-pyloroplasty if associated with gastroduodenal ulcer.
  • Antireflux surgery may not eliminate the need for future pharmacologic treatment.

Endoscopic Treatments for GERD

• The Stretta procedure is a radiofrequency energy delivery system used to provide a thermal burn to the gastroesophageal junction.
• The EndoCinch procedure uses an endoscopic sewing device to create pleats with a series of sutures passed through adjoining folds at the proximal fundus.
• These procedures are designed to decrease reflux symptoms by tightening the lower esophageal sphincter.
• Enteryx, an endoscopically implanted device, prevents reflux of gastric acid into the throat. The device is permanently placed and may eliminate the need for pharmacologic treatment of GERD symptoms.

Complications

• Esophageal stricture formation
• Ulceration of the esophagus, with or without fistula formation
• Aspiration, may be complicated by pneumonia
• Development of Barrett's esophagus—presence of columnar epithelium above the gastroesophageal junction associated with adenocarcinoma of the esophagus

Nursing Interventions and Patient Education

• Teach the patient about prescribed medications, adverse effects, and when to notify the health care provider. PPIs may interact with carbamazepine, cyclosporine, diazepam, diclofenac, digoxin, iron, ketoconazole, lidocaine, methotrexate, metoprolol, nifedipine, phenytoin, propranolol, quinidine, theophylline, and warfarin.
• Inform the patient about medications that may exacerbate symptoms.
• Advise the patient to sit or stand when taking any solid medication (pills, capsules): emphasize the need to follow the drug with at least 100 mL of liquid.
• Familiarize the patient and family with foods and activities to avoid, such as fatty foods, garlic, onions, alcohol, coffee, chocolate, and peppermint.
• Caution the patient against straining, bending over, tight-fitting clothes, smoking.
• Encourage the patient to sleep with the head of the bed elevated (not pillow elevation).
• Encourage a weight-reduction program if the patient is overweight to decrease intra-abdominal pressure.

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