Gastro-Oesophageal Reflux Disease, Treatment and Nursing Interventions - Assignment Example

Gastro-oesophageal reflux disease (GORD). Pathophysiology of the disease process 44 year old Sally has been suffering from heart burn which is due to gastro oesophageal reflux disease. Normally, the lower oesophagus is protected from reflux by anti-reflux mechanism –the lower oesophageal sphincter (LES) and the anatomic configuration of the gastro oesophageal junction. The LES is a localized area of specialized smooth muscle cited at the distal end of the oesophagus, below the diaphragm. It is normally contracted, thus creating a zone of high pressure; thereby preventing the passage of gastric contents in to the oesophagus. In normal subjects, LES relaxes during swallowing. Even if it relaxes during other times, it is only transient. Also, since this sphincter is situated below the diaphragm, intra abdominal pressure and oblique entry of the oesophagus in to the stomach further enhance its protective mechanism (Sawyer, 2005). Reflux occurs when the LES- gastric pressure gradient is lost. The incompetence of LES may be either primary, or secondary due to various conditions like scleroderma, myopathies, pregnancy, female sex hormones, smoking, intake of smooth muscle relaxants, surgical destruction of LES, myotomy or balloon dilatation, and oesophagitis. In hiatus hernia, the LES is pulled above the diaphragm and the sphincter mechanism is lost. In some patients, the sphincter effect is normal, but it relaxes inappropriately causing reflux (Scott, 1999). Stress and irregular eating habits aggravate reflux as in the case of Sally. Once reflux starts occurring, the acidic gastric contents bathe the lower oesophageal mucosa and damage it causing oesophagitis. The extent of damage occurring depends on the mucosal protective mechanisms and the amount and duration of the refluxed material remaining in the oesophagus which in turn is affected by the frequency of episodes, quantity per episode, clearing of the oesophagus by secondary peristalsis and gravity and neutralizing action of the alkaline saliva. Depending on the extent of damage the oesophagitis can be mild or erosive. In later stages, sub mucosal fibrosis can occur, leading to peptic stricture. Most of the times, these strictures are short and only in the lower oesophagus. Prolonged insult by the reflux contents to the squamous epithelium of the lower oesophagus can lead to Barrett’s oesophagus, where in the mucosa develops in to columnar epithelium. This may be further complicated by peptic ulcer or long peptic stricture (high up in to the middle or upper oesophagus). Rarely, adenocarcinoma can complicate Barrette’s oesophagus (Sawyer, 2005; Scott, 1999). Treatment and nursing interventions Management of GORD in Sally depends on the frequency and severity of symptoms, the adequacy of the response to treatment, and the presence of complications. The 3 main treatment aspects are life style modification, acid suppressant therapy and surgery. Lifestyle modifications are first-line therapy for any patient with GORD.  These include weight loss, head of bed elevation and cessation of triggering agents like smoking, alcohol and coffee. How far these modifications help the patient is not yet clear. A study by Veuqelers and others (2006) reported that successful promotion of healthy body weight and diets high in vitamin C may substantially reduce the incidence of this disease. Another study by Kaltenbach and others (2006) suggested that only weight loss and head of bed elevation were effective and that there was no evidence supporting an improvement in GORD measures after cessation of tobacco, alcohol, or other dietary interventions. But Kurawaso (2007) argued that since smoking and alcohol decreased LES pressure, stopping them would help in the management of GORD. However currently, mild heart burn is managed with life-style changes and an occasional antacid. If these initial measures do not help the patient, like in case of Sally, pharmacological management with acid suppressants with either H2 receptor antagonists (HRA) or proton pump inhibitors (PPI) must be considered. Before starting these medications, the physician must assess the severity of the disease. PPI or HRA may be used as the first line. Many prefer to start with HRAs for 4 to 8 weeks and then shift to PPI if there is no improvement. This is called step-up therapy. Some others prefer to aggressively attack with PPIs and then gradually taper to HRA. This is known as step down therapy. The 'No-step' PPI therapy (i.e. continuous PPI therapy) is another relevant option. After an initial remission, long-term PPI therapy is an appropriate form of maintenance therapy in many patients (Bak, 2004). Which is more effective is not yet clear. According to Pettit (2005), H2RAs can provide effective symptomatic relief, particularly in patients with milder GERD, but become less-effective over time and PPIs are the agents of choice for the suppression of gastric acid production and have become the mainstay of therapy for acid-related diseases. This is because PPIs produce significantly faster and more complete symptomatic relief, significantly faster and more complete healing of erosive GERD compared with H2RAs and are also significantly more effective at preventing relapse of erosive oesophagitis. According to Inadomi and Fendrick (2005), no single strategy will be optimal for the entire population with GERD symptoms and hence therapy should be tailored to individual patients. But, one has to know that long-term acid suppressive therapy, as with the use of PPIs, causes proliferation of the endocrine cells of the stomach, leading to hypergastrinemia (Pohle, 2000). Some experts recommend addition of promotility drugs and foam barriers to existing treatment to enhance the effects of acid suppressants (Heidelbaugh, 2003). If at the time of evaluation, there are symptoms or signs that suggest complicated GORD or a disease other than GORD, or if the relief of symptoms with H2 antagonists or PPIs is not satisfactory, a further evaluation by endoscopy (EGD) definitely should be done. If the esophagus is normal and no other diseases are found, strength HRAs or PPIs should be advised. If oesophagitis, ulceration, stricture or Barrette’s oesophagus is detected, then PPIs must be given to heal damage (Heidelbaugh, 2003). Surgery must be considered in Sally only if she does not respond to drugs, especially if she has a tendency to develop aspiration pneumonia. The surgical procedure that is done to prevent reflux is technically known as fundoplication and is called reflux surgery or anti-reflux surgery. This can be done either through laparotomy or through laparoscopy. Presently, laparoscopic antireflux therapy has become a very commonly performed procedure because of its minimal invasion. In their study, Papasavas and colleagues reported that laparoscopic fundoplication can successfully eliminate GERD symptoms and improve quality of life and that significant reduction in the need for chronic GERD medical treatment 2 years after antireflux surgery could be anticipated (Papasavas, 2003). Similar reports were demonstated by Granderath and colleagues (2002). They reported that though the patients had esophageal dismotility for 3-5 years, the over all out come was good. The effectiveness of endoscopic treatments remains uncertain. 3 types of endoscopic treatments are in vogue. These are endoscopic plication technique, endoscopic injection therapy and endoscopic radioablation. Rothstein and others (2001) studied the benefits of endoscopic fundal plication and found that the initial reduction in symptoms was not lasting and 52.5% of the patients had to continue drug therapy. In another study by Maple and others (2001), 33% of patients who underwent endoscopic gastric placation for chronic GORD, continued to need PPIs. Hence it can be assumed that endoscopic fundo-plication treatment may not be of much benefit to the patient in the long run. Endoscopic injection therapy is still under consideration. LES injection therapies act by either bulking at the gastro-oesophageal junction, leading to loss of sphincter compliance and distensibility or by causing chronic inflammation, fibrosis, and encapsulation. The advantage with this type of therapy is that it can be easily administered in an outpatient setting without the need for general anesthesia and is reproducible, safe and durable. However, there are not many studies showing the benefits of this therapy. In most of the studies, individuals treated with LES injections represented only a select subgroup of the overall population of refluxers and they had uncomplicated GERD with typical reflux symptoms of heartburn or regurgitation that have responded to PPIs. Patients who have severe anatomic derangements were excluded (Watson, 2005). Hence, the benefits of these endoluminal therapies are not yet established. The efficacy of endoscopic radio ablation is also not well established. This method acts by reducing the frequency of transient lower esophageal sphincter relaxations triggered by gastric distension. DiBaise and others studied the efficacy of endoluminal delivery of radiofrequency energy to the gastro-oesophageal junction in uncomplicated GERD. They concluded that this method provides effective symptom relief over the short term in patients with uncomplicated gastro-oesophageal reflux disease. However, there are not many case-control trials supporting the benefits of this form of treatment. Also, whatever studies have been done, they are on small scale and on uncomplicated reflux cases. Hence we can conclude that lifestyle modification and pharmacotherapy form the first line of management of GORD in Sally. However, in the course of treatment if she is unresponsive or develops any complications, laparoscopic surgery will be a better option than endoscopic therapies. Outcome Chronic reflux can lead to a number of serious problems, such as bleeding ulcers in the esophagus, scarring leading to narrowing of the esophagus, (stricture) and Barrett's esophagus, a condition that may lead to cancer. This results in difficulty of swallowing solid foods. Chronic reflux may also be associated with aspiration pneumonia. The ulcers can be painful and may lead to anemia. Other manifestations of gastro-oesophageal reflux include chest pain, sore throat, hoarseness, excessive salivation (water brash), a sensation of a lump in the throat, and inflammation of the sinuses (sinusitis). Shaheen and David (2002) have reported strong evidence supporting the association of GORD and adenocarcinoma of the esophagus. They however suggested that the risk of cancer in any given individual with GERD is low. Outcome in GORD can be measured by relief in symptoms and improvement in quality of life. GORD is extremely common, and most patients are treated empirically. Those with mild symptoms like heart burn, as in the case of Sally respond easily to lifestyle modification and occasional antacids. However, those who are not responsive to initial management may need more severe therapies. Who should consider surgery or, perhaps, endoscopic treatment for GERD? PPI therapy usually controls symptoms and mucosal damage in more than 80 percent of patients with GERD. Surgery should be considered in Sally only if she has regurgitation that cannot be controlled with drugs or if she requires large doses of PPI or multiple drugs to control her reflux (Kripke, 2005). There are no studies, however, demonstrating the superiority of surgery over drugs for the treatment of GERD and its complications. Spechler and colleagues (2001) did a long-term follow-up in a group of patients randomized to receive medication or surgery and found that after 10 years, 92 percent of the patients randomized to medical therapy were still taking medication, and 62 percent of the patients initially treated with surgery were again taking antireflux medications. Similar results were demonstrated by Rothstein and others (2001) and Maple and others (2001). The best surgical outcome is in patients whose symptoms responded completely to PPI therapy (Jackson, 2001). Also, antireflux surgery may not be possible in some patients who have had previous upper abdominal surgery and may be less effective in extremely obese patients (Perez, 2001). Even, the new endoscopic surgeries do not demonstrate efficacy. Complications of the new endoscopic techniques include chest pain, fever, infection, dysphagia, perforation, bleeding, and even deaths (after radiofrequency application). Patient education The first and foremost in the management of GORD is patient education. Nurses, doctors and other health professionals should help Sally understand about the disease, the treatment and the outcomes. Of utmost importance is education about lifestyle management which is nothing but a combination of several changes in habit, particularly related to eating. Sally should be advised to lie down in a semi-prone position, by partially elevating the upper part of her body in bed. This is important because, absence of gravity effect while lying down leads to increased reflux and reflux at nights is more harmful (because stays for longer time) and may cause aspiration pneumonia. Reflux also occurs less frequently when patients lie on their left rather than their right sides. Reflux is worse following meals because of distension of abdomen and increased transient relaxations of the lower esophageal sphincter. Hence Sally should be recommended to eat smaller quantities in increased frequency. Also, she should be advised not to go to bed immediately after a meal. Certain foods like chocolate, peppermint, alcohol and caffeinated drinks; stress and smoking are known to reduce the pressure in the lower esophageal sphincter and thereby promote reflux. Such things and other foods which Sally has noticed to precipitate symptoms should also be avoided. Chewing gum may be advised to her. It stimulates the production of more bicarbonate-containing saliva and increases the rate of swallowing (Heidelbaugh, 2003). And of course the most important aspect is to achieve weight loss, in case she is obese because obesity aggravates reflux (Veuqelers, 2006). For this regular exercise, controlled diet and avoidance of fatty foods and sweets should be advised. Also, medications that may potentiate GERD symptoms, including calcium channel blockers, beta agonists, alpha-adrenergic agonists, theophylline, nitrates, and some sedatives should be avoided. Wearing clothing that is tight around the waist must also be avoided (Heidelbaugh, 2003). Word count : 2216 Reference List Bak, Y.T. (2004). Management strategies for gastroesophageal reflux disease. J Gastroenterol Hepatol., 19, Suppl 3, 49-53. Granderath, F.A., Kamolz, T., Schweiger, U. M., Pasiut, M, Wykypiel,H., & Pointner, R. (2002). Quality of life and symptomatic outcome three to five years after laparoscopic Toupet fundoplication in gastroesophageal reflux disease patients with impaired esophageal motility. Current opinion gasteroenterol., 183(2),110-6. Heidelbaugh, J.J., Nostrant, T.T., Kim, C & Harrison, R.V. (2003). Management of Gastroesophageal Reflux Disease. American Family Physician, 68 (7). Retrieved on 12th Aug, 2007 from http://www.aafp.org/afp/20031001/1311.html. Inadomi, J. 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