Faculty of Nursing

Gastroesophageal reflux
(GERD)

Prepared by/
Eman Abdelmobdy Ali

Supervised by/
Dr. Enshrah Roshdy

(2016-2017)

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Outlines:
Introduction

Definition

Pathophysiology

Causes

Clinical manifestations

Complications

Diagnostic studies

Treatment

Nursing management

Reference

Objectives:
By the end of this lecture the attendance will be able to:-

Discuss the definition of GERD.

Discuss the pathophysiology and causes of GERD

Discuss clinical risk factors and manifestations of GERD.

Discuss complications of GERD.

How to diagnose and treat GERD.

Nursing care of GERD.

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 Introduction
Gastro esophageal reflux disease (GERD) chronic disease commonly known as heart
burn. Backflow of gastric contents into the esophagus.
GERD is the most common upper GI problem, Persistent reflux can cause reflux
esophagitis ( inflammation of the esophageal mucosa).
Definition
Is a chronic symptom of mucosal damage caused by reflux of stomach acid into the
lower esophagus.
Pathophysiology
Normally , gastric contents don`t back up into the esophagus because the cardiac
sphincter creates pressure enough to close it.Reflux occurs when cardiac sphincter
pressure is deficient or pressure in the stomach exceeds cardiac sphincter pressure.
Decreased LES pressure can be due to certain foods (e.g., caffeine, chocolate,
peppermint) and drugs (e.g., anticholinergics).
When this happens, the cardiac sphincter relaxes, allowing gastric contents(HCL and
pepsin), to regurgitate into the esophagus.The acidity of the gastric content and duration
of contact with esophageal mucosa are related to the degree of mucosal damage.
Causes
Obesity is a risk factor for GERD, the intra abdominal pressure is increased, which can
exacerbate GERD.Cigarette and cigar smoking can also contribute to GERD.
- A common cause of GERD is :
1. Hormonal changes during pregnancy.
2. A weak lower esophageal sphincter.
3. Hiatal hernia.
4. Slow digestion.
5. Overfull stomach.

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1. Hormonal changes during pregnancy: Heartburn is common during pregnancy,
because the hormones can cause the LES to relax.
2. A weak lower esophageal sphincter: If this
valve is weak, it won't close normally, and reflux will occur more often.
3. Hiatal hernia: A hiatal hernia is a condition in which a small part of your stomach
bulges through a hole in your diaphragm. This hole is called a hiatus. Its a normal,
anatomically correct opening that allows your esophagus to connect to your stomach.
4.Slow digestion: If food stays in your stomach too long before it goes to the small
intestine, the stomach contents are more likely to get pushed up into the esophagus and
cause heartburn.
5.Overfull stomach: Having a very full stomach increases the chance that the valve will
relax and let stomach juices back up into your esophagus.
Clinical manifestations
1. Heart burn:
is the most common clinical manifestation is a burning, tight sensation felt beneath the
lower sternum and spreading upward to the throat or jaw ,it may occur after ingestion
of food or drugs that decrease the LES pressure ( e.g. alcohol, chocolate ,fatty foods,
nicotine, Peppermint, and caffeine) or directly irritate the esophageal mucosa.
2. Dyspepsia:
Pain or discomfort centered in the upper abdomen .. Symptoms of dyspepsia include:
- Burping
- Nausea after eating
- Stomach fullness .
- Upper abdominal pain and discomfort

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3. Regurgitation: It is described as hot, bitter, or sour liquid coming into the throat or
mouth. Hypersalivation may also be reported.
Patient may also report respiratory symptoms, including wheezing, coughing, and
dyspnea. Nocturnal discomfort and coughing can awaken the patient, resulting in
disturbed sleep patterns.
4.Otolaryngologic symptoms:
include hoarseness, sore throat, a globus sensation (sense of a lump in the throat),
and choking.
Complications
1- Esophagitis :
is a common complication of GERD. Repeated esophagitis may lead to scar tissue
formation, stricture, and dysphagia.
2- Barretts esophagus (esophageal metaplasia):
in which the cells that line the inside of the esophagus are replaced by cells similar to
those that line the inside of the stomach and intestine. Barrett's esophagus is not
common, but it can lead to cancer of the esophagus.
3- Respiratory complications :
Cough, bronchospasm and laryngospasm. These complications are due to irritation of the
upper airway by gastric secretions.
Asthma, chronic bronchitis, and pneumonia may develop as a result of aspiration into the
respiratory system.
4- Tooth decay: especially in the posterior tooth, because stomach acid gets into the
mouth and wears away tooth enamel.

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 DIAGNOSTIC STUDIES
Questions about symptoms firstly asked such as having frequent uncomfortable feeling of
burning, warmth, heat, or heartburn.Doctor may prescribe medicines to treat GERD
without doing any other tests.If medicines don't help, other tests may be done . These
may include:
1. An upper gastrointestinal endoscopy:
This allows looking at the inner lining of esophagus, stomach, and the first part of your
small intestine (duodenum) through a thin, flexible viewing tool called an endoscope.It
helps in assessing the LES competence and the degree of inflammation ,potential
scarring, and strictures. Biopsy and cytologic specimens can differentiate stomach or
esophageal carcinoma from Barretts esophagus.In addition, the degree
of dysplasia .
2. Esophageal tests:
These may be done to find out how well the muscles in the esophagus move food, or to
monitor how often acid gets into the esophagus and how long it stays there.
3. An upper gastrointestinal series:
looks at the upper and middle sections of the gastrointestinal tract. The test uses barium
contrast material, fluoroscopy, and X-ray.
TREATMENT
Treatment is aimed at:
- Reducing backflow, or reflux, of stomach acid and juices into the esophagus.
- Preventing damage to the lining of the esophagus, or helping to heal the lining if
damage has occurred.
- Keeping GERD from coming back.
- Preventing health problems that can occur because of GERD.

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Most patients with GERD can successfully manage this condition through lifestyle
modifications and drug therapy. When these therapies are ineffective, surgery is an
option.
1. Lifestyle Modifications
- Teach the patient with GERD to avoid factors that trigger symptoms .
- Give particular attention to diet and drugs that may affect the LES, acid secretion,
or gastric emptying.
- Recommend weight reduction if the patient is overweight.
- Encourage patients who smoke to stop.
- If stress seems to cause symptoms, discussmeasures to cope with stress.
2. Nutritional Therapy
Some foods can aggravate symptoms. Teach patients to avoid foods that decrease LES
pressure, such as chocolate, peppermint, tomatoes, fatty foods, coffee, and tea, which
predispose them to reflux. Also teach patients to avoid milk, especially at bedtime, since
it increases gastric acid secretion. Small, frequent meals help prevent over distention of
the stomach.Saliva production can be increased by chewing gum, which may help
patients with mild symptoms of GERD.
Tell the patient to avoid late evening meals and nocturnal snacking, and to take fluids
between rather than with meals to reduce gastric distention.
3. Drug Therapy
Drug therapy focuses on:
- Decreasing volume and acidity of reflux.
- Improving les function.
- Increasing esophageal clearance.
- Protecting the esophageal mucosa.

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 Drugs to treat GERD are:
- Antacids, H2 blockers, and proton pump inhibitors are usually tried first.
- Antacids neutralize stomach acid and relieve heartburn.
- Acid reducers. These include:
- H2 blockers reduce the amount of acid in the stomach.
- Proton pump inhibitors, reduce the amount of acid in the stomach.
4.Surgical therapy
Surgery may be an option when:
Medicines don't completely relieve symptoms.
A person doesn't want or isn't able to take medicines over an extended period of time to
control GERD symptoms.Along with reflux, a person has symptoms such as asthma,
hoarseness, or cough that don`t adequately improve when treated with medicines.
o Fundoplication surgery
This surgery strengthens the valve between the esophagus and stomach (LES) to keep
acid from backing up into the esophagus easily. It relieves GERD symptoms and
inflammation of the esophagus (esophagitis).
Types of surgery may include:
- Partial fundoplication. Partial fundoplication involves wrapping the stomach only
partway around the esophagus.
- Full fundoplication involves wrapping the stomach around the esophagus so that it
completely encircles it.
o Gastropexy
A gastropexy attaches the stomach to the diaphragm so that the stomach cannot move
through the opening in the diaphragm into the chest. Gastropexy is done less often than
fundoplication.

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 Nursing management
1- Nursing Diagnosis:
Imbalanced nutrition less than body requirements related toinability to intake enough
food because of reflux and heartburn
Desired Outcomes:
Patient will ingest daily nutritional requirements according to his activity level and
metabolic needs.
Nursing intervention:
1. Accurately measure the patients weight and height.
2. Obtain a nutritional history.
3. Encourage small frequent meals of high calories and high protein foods.
4. The patient is instructed to eat a low-fat diet; to avoid caffeine, tobacco, beer, milk,
foods containing peppermint , and carbonates.
5. Instruct to remain in upright position at least 2 hours after meals; avoiding eating 3
hours before bedtime.
6. Instruct patient to eat slowly and masticate foods well.
7. To maintain normal body weight
2- Nursing diagnosis:
Acute Pain related to gastroesophageal reflux, coughing, aspiration, irritated esophageal
mucosa and irritated oral cavity from reflux.
Desired Outcomes
Client will report pain is relieved.
Nursing intervention:
1. Assess for heartburn.
2. Carefully assess pain location.
3. Instruct the patient to elevate the head of the bed to approximately 30 degrees.

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 4. Teach the patient to avoid food and activities that cause reflux (e.g., late-night
eating).
5. Instruct patients to contact their health care provider if symptoms persist.
6. Instruct the patient to avoid situations that decrease lower esophageal sphincter
pressure or cause esophageal irritation.
7. Instruct the patient to avoid tight-fitting clothes.

3- Nursing diagnosis: Risk for aspiration related to weakness affecting the lower
esophageal sphincter and impaired swallowing.
Desired Outcomes:
Client will maintain patent airway.
Nursing intervention:
1. Assess for pulmonary symptoms resulting from reflux of gastric content including
nocturnal wheezing, bronchitis, asthma, morning hoarseness, and cough.
2. Assess for nocturnal regurgitation in which the patient awakens with coughing,
choking, and a mouthful of saliva.
3. Assess patients ability to swallow and the presence of gag reflex.
4. Avoid placing patient in supine position, have the patient sit upright after meals.
5. Instruct patient to avoid acidic juices, alcoholic drinks, bedtime snacks, and foods
high in fat.
6. Elevate head of the bed to prevent aspiration by preventing the gastric acid to flow
back in the esophagus.
7. Avoid nasogastric intubation for more than five (5) days, the tube interferes with
sphincter integrity and allows reflux, especially when the patient lies flat.
8. Instruct the patient to chew food thoroughly and eat slowly.
9. If the patient has dysphagia, put the patient on NPO and notify physician.

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4- Nursing diagnosis:
Deficient Knowledge related to lack of information regarding condition/disease process.
Desired Outcomes:
Client will have increased knowledge of actions that reduce reflux.
Nursing intervention:
1. Assess patient for information needed and ability to perform actions independently.
2. Provide patient with information regarding disease process, health practices that
can be changed, and medications to be utilized.
3. Instruct patient regarding eating small amounts of food followed by a small
amount of water. Instruct to remain in upright position at least 2 hours after meals,
and to avoid eating within 3 hours of bedtime.
4. Instruct patient to avoid bending over, coughing, straining at defecations, and other
activities that increase reflux.
5. Instruct patients to eat slowly, chew foods well and maintain a high-protein,
low-fat diet.
6. Instruct patient to avoid temperature extremes of food, spicy foods, and citrus, and
gas forming foods.
7. Instruct patient regarding avoidance of alcohol, smoking, and caffeinated
beverages.
8. Instruct patient in medications, effects, side effects, and to report to physician if
symptoms persist despite medication treatment.

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Reference
1. Lewis, S.L , Bucher. L , Dirksen, S. R and Harding M.M (2014): Medical
surgical nursing, assessment and management of clinical problems, 9thed,
Mosby, (931-935)
2. WebMed (2017): GASTROESOPHAGEAL REFLUX DISEASE (GERD).
Available at (http://www.webmd.com/heartburn-gerd/tc/gastroesophageal-reflux-
disease-gerd-topic-overview). access at :- 19/3/2017.

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