Definition/Description[edit | edit source] Show
Gastroesophageal reflux disease (GERD), sometimes referred to as esophagitis, is a complex disease with serious complications. It results from reflux (backward flow) of the stomach contents into the esophagus and causes trouble symptoms at least two times a week. Reflux of infectious agents, chemical irritants, physical agents, such as radiation and nasogastric intubation can cause GERD and can irritate and inflame the esophagus causing heartburn, belching, sore throat and other symptoms. [1][2][3][4] Heartburn is not another word for GERD, but is the most common symptom of the condition.[1] GERD is the most common cause of heartburn, but there are other disorders that contribute to heartburn.[4] Although GERD is common in our society, it is rarely life-threatening, but can severely limit daily activities and productivity.[5] GERD can occur in infants and children. Infants typically grow out of the disease, and children with GERD present the same as adults.[2] [6] [7] Prevalence[edit | edit source]GERD is the most common gastrointestinal diagnosis recorded during visits to outpatient clinics. It is estimated that 14-20% of adults are affected, but the estimates are based on self-reported chronic heartburn. [4] Studies have shown that GERD is clinically silent in 24% of cases in which patients had difficult to control asthma[8]. It can often be seen in:[8]
Characteristics/Clinical Presentation[edit | edit source]Pain in the lower substernal area can arise as a result of relfux or GERD; it is commonly described as "heartburn" or "indigestion". GERD is also described as gripping, squeezing or burning sensations in the substernal area.[2][3] Onset of GERD can occur when lying flat on the back, after meals, or bending forward and is usually worse at night. It is important to note that reflux or GERD is often confused with angina or a heart attack and should be reported to the doctor. GERD is not typically exercise induced and is relieved with antacids; this can help differentiate between angina/heart attack and reflux. Chest pain referred from the upper gastrointestinal tract can radiate from the chest posteriorly to the upper back or interscapular or subscapular regions from vertebrae T10 - L2. Common Symptoms:
Associated Co-morbidities[edit | edit source]Patients with a past medical history of alcoholism, cirrhosis of the liver, peptic ulcers, esophageal varices, esophageal cancer, and long term use of NSAID's are more likely to have symptoms of GERD and should have diagnostic tests performed to rule out more severe conditions or diagnose GERD. It is typical for patients with GERD to have multiple risk factors. Some of the factors that predispose patients to pathologic reflux are: [4][1]
Medications[edit | edit source]Medications used to treat symptoms of GERD include: Antacids, Histamine 2 Receptor Blockers, and Proton Pump Inhibitors. Indefinite treatment with proton-pump inhibitors or H2-blockers as needed to maintain symptom control[2].There are risks associated with long term use of proton-pump inhibitors.[4] Antacids[edit | edit source]
Histamine-2 Receptor Blockers[edit | edit source]
Proton Pump Inihibitors[edit | edit source]
It is essential for the physical therapist to take note of the patient's medications; listen for complaints of headache, constipation, diarrhoea, abdominal pain and dizziness; and report those findings to the doctor. Diagnostic Tests/Lab Tests/Lab Values[edit | edit source]Diagnostic tests are not typically needed unless the symptoms are severe. Physicians will order diagnostic tests to diagnose GERD or other complications if there are severe symptoms, the symptoms are not relieved with medications or the symptoms returned. Severe symptoms include dysphagia, odynophagia, bleeding, weight loss, anemia, and those at risk for Barrett's esophagus.[3][4] Commonly used diagnostic tests used to diagnose GERD are discussed below. Esophagogastroduodenoscopy[edit | edit source]A procedure where a small camera is placed at the end of flexible tube; the tube is inserted into the mouth and down the throat and examines the lining of the esophagus, stomach and upper duodenum[5][9] Barium Swallow[edit | edit source]This is a special type of imaging that requires the patient to drink barium before undergoing an x-ray. This produces clear images of the upper digestive tract.[10] Continuous Esophageal pH Monitoring[edit | edit source]This procedure involves a thin tube being inserted into the esophagus, through the mouth, to measure acid levels and the pH[5] Esophageal Manometry [edit | edit source]This procedure requires a thin tube to be inserted into the esophagus, through the mouth or nose, to measure the pressure of the esophagus[5] Etiology/Causes[edit | edit source]The lower esophageal sphincter (LES) is a ring of muscle fibers that functions to close the opening between the esophagus
and the stomach. When the LES is not functioning properly, the stomach contents (food, liquid, and stomach acid) can move backward into the esophagus causing damage to the esophagus. The backward flow of food from the stomach into the esphophagus is called reflux. [3]
Some of the medications that can cause GERD or make it worse are:[3]
Systemic Involvement[edit | edit source]Musculoskeletal[edit | edit source]Untreated ulcers can cause biomechanical changes in muscular contractions and spinal movement. Patient may present with musculoskeletal deficits or dysfunctions because of the untreated ulcer. It is important for the physical therapist to take a good medical history to reveal actual cause of musculoskeletal
dysfunction. Patients may think that heartburn while lying flat, difficulty swallowing, or chronic cough is unrelated to their recent onset of midscapular pain or thoracic back pain; thus, it is imperative to ask the patient if they have had any symptoms of GERD and if they are being treated by a medical doctor for the
diagnosis.[2] Dental[edit | edit source]GERD can cause irreversible dental erosion of the posterior surface of the teeth. Possible symptoms associated with dental erosion included vomiting, experiencing sour taste, belching, heartburn, stomach ache and pain on awakening. Oral Symptoms include: burning mouth syndrome, tooth sensitivity, loss of the vertical dimension of cculsion and aesthetic disfigurement.[11] Respiratory[edit | edit source]Gastric acid in the airways can cause bronchoconstriction which increases bronchial activity. Acid in the esophagus releases substance P and neurokinin A in the bronchial mucosa causing a neuroinflammatory reflex mechanism and airway edema. An increase in asthma severity is caused from an increase in vagal efferent impulses and the results of acid being in the esophagus and the airways.[12] Gastrointestinal[edit | edit source]GERD is a risk factor for Barrett's esophagus and is linked to esophageal adenocarcinoma. Barrett's esophagus is a precancerous condition, in which the normal squamous epithelium is replaced by specialized metaplastic columnar cell-lined eipthelium.[13] Chronic GERD is a major risk for esophageal adenocarcinoma.[2] Medical Management[edit | edit source]If lifestyle changes and medications do not help the symptoms of GERD, the individual may be considered for surgical management. Nissen Fundoplication[edit | edit source]A surgical intevention, in which the proximal stomach is wrapped around the distal esophagus to create and antireflux barrier and is used as an alternative treatment for chronic GERD when conservative management has not been successful. It was a very common procedure in 1990's, recently not as common due to poor outcomes and patient dissatisfaction[4]. Some associated risks are:
[14] Physical Therapy Management[edit | edit source]Patients with GERD occasionally present to the clinic with atypical head and neck symptoms without complaints of heartburn.[1] It is important for the Physical Therapist to be aware of pain referral patterns for the esophagus. With an atypical presentation, the Physical Therapist may need to ask if the patient has a history of difficulty swallowing, difficulty speaking, chronic dry cough, etc. There are also those patients who attend physiotherapy for other conditions, but have a history of GERD. In this case the Physical Therapist has to be aware of positioning and education on lifestyle modifications if necessary.[1] When treating a patient with GERD[1]:
The Shaker Head-Lifting Exercise[edit | edit source]Research has found that performing the Shaker exercise[1], developed by Dr.Reza Shaker (a gastroenterologist at the Medical College of Wisconsin), can help improve pharyngeal swallowing and dysphagia.[15] It is designed for patients who do not have cervical disc disease, but have dysphagia. The benefits of this technique are:
How to Perform the Technique[edit | edit source]The patient should lie in the supine position on firm, flat surface, without a pillow and arms resting by their sides. They should be instructed to breathe slow and steady throughout the exercise.
Lifestyle Changes[edit | edit source]Changing eating habits and lifestyle along with avoiding foods that may trigger symptoms can help decrease the symptoms of GERD. [1][3] There are several foods and beverages that are linked to causing symptoms of GERD (i.e. heartburn) and linked to making the symptoms worse. Physicians suggest people with GERD should avoid these foods along with other foods or activities that have been linked to causing symptoms in the specific individual. Foods and beverages known to cause an increase in symptoms:
Lifestyle and eating habit changes that can help decrease the onset of heartburn and other GERD symptoms:
Differential Diagnosis[edit | edit source]
Case Reports/ Case Studies[edit | edit source]
References[edit | edit source]
Which teaching is a priority for the patient with gastroesophageal reflux?Don't eat large meals. Eat smaller meals more often. This will allow you to eat the same amount of food, but in smaller portions that will be easier to digest. Don't lie down for at least 2 to 3 hours after eating.
Which instruction should the nurse include in the discharge teaching for a client who has gastroesophageal reflux?Avoid lying down after meals. Avoid eating late at night. Elevate the head of your bed by 6 inches. You can do this by placing wooden blocks or bed risers under the head of your bed.
Which interventions would the nurse include in the plan of care for a client with gastroesophageal reflux disease GERD )?Nursing Interventions. Accurately measure the patient's weight and height. ... . Obtain a nutritional history. ... . Encourage small frequent meals of high calories and high protein foods. ... . Instruct to remain in upright position at least 2 hours after meals; avoiding eating 3 hours before bedtime.. Which self care behavior would benefit a client with gastroesophageal reflux disease?These lifestyle changes can help ease the symptoms of GERD or even prevent the condition: quitting smoking. avoiding alcohol. losing weight if you are overweight.
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