Gastroesophageal Reflux (GERD) Nursing CE Course

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Syllabus

Gastroesophageal Reflux Disease

At the end of this learning activity, the reader should be able to:

1. Define gastroesophageal reflux disease (GERD).

2. Discuss the pathophysiology of GERD.

3. Identify GERD risk factors.

4. Identify signs and symptoms of GERD.

5. Describe diagnostic tests for GERD patients.

6. Discuss the recommended treatment guidelines for GERD.

7. Describe options for GERD treatment involving surgery.

8. Discuss nursing management using the nursing process as a framework for care for patients with GERD.

Upon completion of this module you will be able to discuss the pathophysiology and causes of GERD, identify the risk factors, signs and symptoms, and nursing management for GERD.

Gastrointestinal esophageal reflux disorder (GERD) is a common gastrointestinal digestive disorder identified by names such as acid reflux or simply as reflux. Ferri (2017) stated GERD may be defined as a condition that develops when the reflux of stomach contents causes at least two episodes of dyspepsia per week, and/or associated complications. GERD is prevalent worldwide and increasing each year across the continents (Eusebi et al., 2018). GERD symptom descriptions differ among countries, but GERD prevalence was overall significantly higher in subjects ≥50 years old, smokers, NSAID users, and obese individuals (Patti, 2019).  According to El-Serag, Sweet, Winchester, and Dent (2014), the North American continent has the highest rates of GERD worldwide. It is estimated that 7%-10% of Americans experience symptoms of GERD on a daily basis. It is suspected GERD may be underreported by patients due to the availability and effectiveness of over-the-counter (OTC) medications or home remedies used to control GERD symptoms (Patti, 2019). Other populations affected by GERD symptoms more commonly include pregnant women, infants, and children. Ethnicity may also influence the development of GERD with Caucasians having more severe manifestations and complications than other ethnicities (Dhingra & Younes, 2015; Hunt et al., 2017). Studies indicate there is a genetic risk factor for GERD with a 40% heritability (Sommers, 2019). According to Kim, Kim, and Kim (2016) males and females have about the same level of GERD prevalence. However, females are diagnosed at a higher frequency with nonerosive reflux disease (NERD), while males more often have an erosive esophagitis diagnosis. The erosive esophagitis may lead to Barrett’s esophagus and carcinoma (El-Seraq et al., 2014).

Terms often used when discussing GERD include symptom descriptions such as dysphagia, which is defined as difficulty in swallowing (O’Toole, 2013).  Esophageal dysphagia is defined as the sensation of food being stuck in the neck or chest. Patients often describe heartburn, indigestion, or acid indigestion as a burning pain, which occurs retrosternal and may radiate to the neck or throat. Dyspepsia is the medical term used to document indigestion or heartburn symptoms (Nordqvist, 2017). Odynophagia is a term used to describe painful swallowing, which may occur as a result of the irritated esophageal tissue and indicate the presence of erosive or ulcerative esophagitis. If a patient complains of “something stuck in the back of their throat,” the term, globus sensation may be documented (O’Toole, 2013). 

Pathophysiology of GERD

GERD occurs when stomach acid frequently flows back up into the esophagus, oral cavity, or lungs (Ferri, 2017).  The esophagus is a musculofibrous tube that transports food from the pharynx to the stomach via peristaltic movement and a small amount of mucous secretion. It is approximately 10 inches in length and located at each end of the esophagus are sphincters. The purpose of the upper sphincter is to prevent air from getting into esophagus while breathing. The last two inches of the esophagus is called the lower esophageal sphincter (LES). Its purpose is to prevent gastric reflux, which is the backwards flow of either gastric or duodenal contents into the esophagus past the LES. Normally, the LES creates enough pressure around the lower end of the esophagus to keep it closed and prevent acid reflux. Conditions contributing to the impaired contraction of the LES include certain foods, fluids, gastric distention, cigarette smoking, lying recumbent after meals, and medications. Table 1 lists examples of medications, foods, and medical conditions which may alter LES pressures (Ferri, 2017; Tenorio & Ali, 2017). 

Drugs that may alter the LES pressure include anticholinergics, diazepam (Valium), morphine (MS-IR), calcium channel blockers, and meperidine (Demerol). According to Mungan and Pinarbasi Simsek (2017), certain drugs affect esophagogastric motility which may lead to an increased esophageal exposure to the acid reflux. Medications may damage the esophageal or stomach mucosa by inhibiting cyclooxygenase (COX) enzymes and increasing gastric acid secretion. Other medications can also reduce gastric emptying time and reduce LES by relaxing smooth muscles.  Anticholinergics alter the peristaltic function, depress LES, reduce saliva, and result in decreased clearance of food in the esophageal area so that acidic materials remain longer in the esophageal area. Calcium channel blockers and non-steroid anti-inflammatory drugs (NSAIDs) can lead to GERD or increased symptoms of GERD. Antidepressant medications, such as tricyclic antidepressants, can also lead to GERD development related to the anticholinergic effects and the reduction of LES (Mungan & Pinarbasi Simsek, 2017). 

If the patient has a hiatal hernia, it may lead to GERD. A hiatal hernia is thought to weaken the LES and occurs when the upper portion of the stomach moves into the chest through a diaphragmatic hiatus (Tenorio & Ali, 2017).  Conditions which increase intraabdominal pressure such as obesity or pregnancy may also lead to GERD symptoms (Ness-Jensen, Hveem, El-Serag, & Lagergren, 2016). The elderly patient may also demonstrate weakened LES control (Sommers, 2019).

Risk Factors

GERD risk factors vary and include factors which lower the LES pressure such as those listed below in Table 1. Other factors which increase the risk for GERD include smoking, overeating (especially at night), eating fried or fatty foods, and drinking alcohol or coffee (Ferri, 2017). Stress can also play a role in GERD development, whether it is physiological or psychological in nature. The activation of the “flight or fight” response may lead to ischemia and ulceration. Stress can decrease prostaglandins which are produced in the cell by the COX enzymes and usually protect the stomach from acid effects (Tenorio & Ali, 2017). 

Table 1: Possible Causes of a Reduction in LES Pressure

(Ferri, 2017; Patti, 2019; Tenorio & Ali, 2017) 

Complications from GERD can include Barrett’s esophagus, esophageal strictures, and ulcers (Sommers, 2019). Barrett’s esophagus is a condition where the esophageal mucosa changes due to the continued exposure to acid. The cells in this area begin to resemble the lining of the small intestine instead of the esophageal mucosa. Barrett’s esophagus is considered a premalignant condition, meaning if it is left untreated, it may develop into esophageal adenocarcinoma (Khieu & Bhimji, 2017).  Esophageal strictures are described as a narrowing or tightening found in the esophagus which can be a result of damage to the esophagus from stomach acid. The damage can cause scar tissue formation which is less flexible/mobile than healthy tissue, which creates esophageal strictures (Ferri, 2017). Esophageal strictures can lead to the patient experiencing dysphagia (Patti, 2019). Esophageal ulcers are open sores that may cause bleeding, pain, and make swallowing difficult for the patient (Tenorio & Ali, 2017; Yamasaki, Hemond, Eisa, Ganocy, & Fass, 2018). An H. pylori infection can damage and inflame the lining of the stomach and small intestine, and about 10% of the time can lead to the development of a gastric ulcer. It is also a risk factor for gastric malignancies (Mayo Clinic, 2017).

Signs and Symptoms

GERD may not always cause signs or symptoms but two of the most common symptoms reported by patients are dyspepsia, often described in layman’s terms as heartburn, and/or regurgitation. Regurgitation describes the backward flow of stomach contents. Other common symptoms include chest pain, dysphagia, a sour or bitter taste in the mouth, or globus sensation (Ferri, 2017; Sommers, 2019). Hoarseness, laryngitis, or respiratory complaints such as chronic cough or asthma symptoms may also be related to GERD (Dickman, Maradey-Romero, Gingold-Belfer & Fass, 2015). With nighttime GERD, the patient may complain of sleep disruption or excessive salivation without the sour taste. Nocturnal hypersalivation may be reported by the patient as being awakened due to coughing or choking from the excessive salivation (Sommers, 2019). Dyspepsia occurs more commonly after meals, especially when the patient eats and does not wait a few hours before retiring to bed. Patients may report taking baking soda or OTC antacids, which improve the symptoms (Patti, 2019). Despite its regularity, GERD symptoms should always be taken seriously by the nurse when reported by the patient. Lee et al. (2017) reviewed the correlation of symptom severity with patient’s quality of life and found that the patients with more severe symptoms had the poorest quality of life. 

According to Sommers (2019), the heals  th history and initial assessment of the patient will provide the foundation for the healthcare team to identify the presence of GERD. The nurse should assess the drug history to include all herbals/supplements, OTC, and prescribed medications for potential causes of dyspepsia or GERD. Gastrointestinal questions prompt the patient to report burning retrosternal pain after eating, excessive flatulence, bloating, eructation (belching), dysphagia, odynophagia, or other symptoms indicative of GERD. A respiratory assessment may point to a chronic cough, worsening of asthma symptoms, or complaints of being hoarse. The psychosocial assessment should evaluate the patient’s stress level, use of tobacco products, and alcohol intake. Family history should also be investigated during this assessment because there is a genetic component to GERD. The nurse should begin formulating a plan of care for the patient after completing the health history and initial assessment. The primary nursing diagnosis may be acute or chronic pain related to GERD and associated inflammation, and interventions would be directed at pain relief. If there are behavioral or lifestyle components contributing to their condition, other applicable nursing diagnoses would be ineffective self-care and knowledge deficits (Sommers, 2019). 

Diagnosis

Typically, a healthcare provider diagnoses GERD based primarily on clinical presentation. El-Seraq et al. (2014) stated there is not a gold standard diagnostic test for GERD. Initially, treatment often begins with prescribed antacid medications and lifestyle modifications as the first line of treatment unless severe symptoms are reported. If the patient does not see improvement in symptoms in 4-8 weeks or their condition worsens, the healthcare provider may order a diagnostic esophagogastroduodenoscopy (EGD) or a barium esophagram (Tenorio & Ali, 2017). An EGD uses a lighted instrument (endoscope) inserted into the oral airway while the patient is under procedural sedation. Diagnostically, the EGD aides in identifying any damage to the tissues of the esophagus, stomach, and upper duodenum. During the EGD, a tissue sample can be obtained for biopsy to determine if adenocarcinoma, erosive or non-erosive disease, or Barrett’s esophagus is present (Patti, 2019).  A barium esophagram, or barium swallow test, may be done to assess for strictures as well as hiatal hernias (Tenorio & Ali, 2017). During the barium esophagram the patient will swallow a liquid contrast (barium), then a series of x-rays will be taken of the pharynx and esophagus.  LES function can be measured with esophageal manometry (Ferri, 2017). 

Additional studies may include an upper gastrointestinal series, which is similar to a barium esophagram, but also includes x-rays of the stomach and duodenum; or esophageal pH testing, which involves a small probe inserted into the lower esophagus through the nostril and left in place for a predetermined time to measure the acidity level in the esophagus (Patti, 2019; Tenorio & Ali, 2017). An H. pylori infection is diagnosed with a carbon breath test, an antigen stool sample, a blood test (less than ideal), or via an endoscopy procedure (Mayo Clinic, 2017).  During this phase of care, the nurse should be sure to educate the patient and/or caregivers about the various tests that the healthcare team plans to use in diagnosing GERD. 

Management of Care

As noted earlier, the initial treatment plan for GERD may include a trial period of prescription medication. Once a treatment plan has been developed, the nurse should emphasize the importance of follow-up visits to evaluate the effectiveness of the treatment plan. The nurse should review with the patient all symptoms to monitor, and if the condition worsens, who to contact or where to go for healthcare in the event of an emergency (Sommers, 2019). GERD discomfort can be treated with lifestyle changes, OTC or prescription medications, or even surgery (Ferri, 2017). Sommer (2019) identified certain lifestyle changes to include eating smaller meals, lowering stress levels, and decreasing or eliminating acidic or fatty foods from the diet. Avoidance of LES lowering factors listed in Table 1 would assist the patient in decreasing GERD symptoms. Patients should be encouraged to lose weight if they are obese in order to lower the intra-abdominal pressure. Also, patients should be counseled to avoid lying down within three hours of a meal and if possible, to elevate the head of their bed on 3-6-inch blocks to enhance esophageal clearance. Measures should be taken to avoid an increase in intra-abdominal pressure due to straining, lifting heavy objects, and restrictive clothing (Sommers, 2019).  Additional instructions should be given to patients regarding decreasing alcohol intake and smoking cessation to reduce reflux symptoms (Ness-Jensen et al., 2016). Nursing care should be directed toward nursing education regarding lifestyle modifications, pharmacological interventions, stress reduction, and dietary changes. A dietary consultation would be beneficial for the patient, especially if weight reduction is needed. Management may also focus on the treatment of any underlying causes which may be contributing to the GERD symptoms (see Table 1, third column). For example, a recent meta-analysis of H. pylori treatment found that “H. pylori eradication therapy is beneficial for symptom relief, reduces the development of peptic ulceration, and leads to histologic resolution of chronic gastritis but does not improve the quality of life and may even result in adverse events” (Du et al., 2016, p. 3487). H. pylori eradication therapy is most often accomplished with a combination of at least two oral antibiotics and a proton pump inhibitor (PPI) or other acid suppressing medication for 7-14 days (Mayo Clinic, 2017).

OTC medications are available to treat GERD symptoms. There are three major categories of medications used to treat GERD symptoms, all of which are now available without a prescription: antacids, histamine-2 (H2) receptor antagonists/blockers, and Proton Pump Inhibitors (PPI). Patients self-medicating with OTC drugs for GERD longer than two weeks should be strongly encouraged to meet with their healthcare provider for further evaluation. Antacids neutralize gastric acid and decrease pepsin production by blocking conversion of pepsinogen to pepsin. They are often used by patients to relieve heartburn and abdominal discomfort. Antacids may contain either aluminum hydroxide and/or magnesium hydroxide. Diarrhea is associated with magnesium hydroxide while constipation can occur with aluminum antacids. Caution should be used in recommending magnesium antacids with renal disease due to hypermagnesemia. Large amounts of aluminum-based antacids can lead to hypophosphatemia and osteomalacia (Tenorio & Ali, 2017). 

H2 receptor antagonists, or H2 blockers, are used for heartburn symptoms, treatment of peptic ulcers, and GERD. Histamine is released in the body due to straining or stress and can cause over-stimulation of hydrochloric acid production by the parietal cells in the stomach. The H2 receptor antagonists partially block the histamine from activating the receptors, thereby decreasing hydrochloric acid secretion. Reduced dosages of H2 blockers are now available OTC. The most common side effect of nearly all H2 blockers is headache. Examples include famotidine (Pepcid), cimetidine (Tagamet), ranitidine (Zantac) and nizatidine (Axid) (Tenorio & Ali, 2017).

 PPIs typically inhibit gastric acid secretion for a longer length of time than H2 blockers by irreversibly blocking the H+/K+ enzyme in the parietal cells of the stomach, or the gastric proton pump. Some PPIs are available OTC. Side effects of PPIs include headache, diarrhea, constipation, abdominal pain, flatulence, fever, vomiting, and nausea. Long term effects of chronic PPI use can include increased risk of hypocalcemia, hypomagnesemia, Clostridium difficile infections, osteoporosis-related fractures, vitamin B12 deficiency, and pneumonia (Sommers, 2019). The long-term safety is not completely known because most research studies have a follow up of 10 years or less (Tenorio & Ali, 2017).

Medications used in the treatment of GERD, including H2 receptor antagonists and PPIs, may be prescribed by the healthcare provider for a specified amount of time in dosages higher than those available OTC. In patients who do not experience relief of their symptoms with prescription medications or if GERD symptoms worsen within 4-8 weeks of daily administration, additional testing may be required. PPI therapy is most often prescribed by healthcare providers for empiric treatment of patients with reflux symptoms due their efficacy and low cost. The nurse should educate the patient on concerns to be reported to the healthcare provider such as significant weight loss or dysphagia. The nurse should warn patients not to self-medicate with OTC medications for heartburn while on prescription medications. Acid suppressant drugs can alter the effects of other medications, impact nutrient absorption, and affect other medical conditions, so it is important to review all medications carefully with the patient at every appointment (Ferri, 2017).

Table 2: Examples of medication classifications used in the treatment of GERD

(Patti, 2019)

If surgical intervention is deemed necessary by the healthcare provider, the most common surgery for GERD is the Nissen fundoplication. The laparoscopic Nissen fundoplication (LNF) was generally found to be more cost-effective than long-term medication therapy for patients suffering from moderate-severe chronic GERD symptoms (Gawron, French, Pandolfino, & Howden, 2014). The Nissen procedure is usually performed laparoscopically to reinforce the LES by wrapping the gastric fundus around the lower portion of the esophagus. Nursing care after surgery would include a focus on pain management, prevention of common surgical complications, emotional support, dietician consult for diet education and/or a weight loss program. The nurse should monitor the patient closely for abnormalities in systems, especially respiratory complaints due to the location of the surgery. The patient will likely require pain management with interventions such as positioning, relaxation techniques, and prescribed analgesics. If a thoracic approach was used for the surgery, the nurse should monitor any drainage from the chest tube if applicable (Sommers, 2019). 

Future Research/Directions

According to the literature, additional research is needed in many areas concerning GERD. Research studies indicate GERD symptoms have increased worldwide and this finding is reinforced by the skyrocketing sales of OTC GERD medications (Gawron et al., 2014). A universally recognized definition of GERD and treatment guidelines would enhance the diagnostic and management process for patients. Along with the lack of truly long-term data, these are noted as limitations in several research studies. Additional research studies are needed on cost-effectiveness versus quality of life for GERD patients regarding treatment options such as medications versus surgical intervention. According to the U.S. National Library of Medicine (Guo Zihao, 2018), there is currently a pilot research study underway on a new system for GERD diagnosis and treatment called EAISMLP. Each letter in "EAISMLP" corresponds with a treatment, such as endoscopy, 24-hour esophageal pH-impedance monitoring, esophagus high resolution manometry and psychological condition. The plan is for a prospective observational study with 200 participants to review treatment options.  Recruitment for the study has not yet taken place at this time (Guo Zihao, 2018). 

References

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Dhingra, S., & Younes, M. (2015, October 13). Reflux esophagitis. Medscape. Retrieved from https://emedicine.medscape.com/article/1610393-overview 

Du, L. J., Chen, B. R., Kim, J. J., Kim, S., Shen, J. H., & Dai, N. (2016). Helicobacter pylori eradication therapy for functional dyspepsia: Systematic review and meta-analysis. World Journal of Gastroenterology, 22(12), 3486–3495. doi:10.3748/wjg.v22.i12.3486

El-Serag, H.B., Sweet, S., Winchester, C.C., & Dent, J. (2014). Update on the epidemiology of gastro-oesophageal reflux disease: A systematic review. Gut, 63(6), 871-880.

Eusebi L.H., Ratnakumaran R., Yuan, Y., Solaymani-Dodaran, M., Bazzoli, F., & Ford, A., (2018).  Global prevalence of, and risk factors for, gastro-oesophageal reflux symptoms: a meta-analysis. Gut, 67(3), 430-440. doi: 10.1136/gutjnl-2016-313589.

Ferri, F. F. (2017). Gastroesophageal reflux disease. In F. F. Ferri (Ed.), 2017 Ferri’s clinical advisor: 5 books in 1 (pp. 497-498). Philadelphia, PA: Elsevier. 

Gawron, A., French, D., Pandolfino, J., & Howden, C., (2014). Economic Evaluations of Gastroesophageal Reflux Disease Medical Management. PharmacoEconomics, 32(8), 745-758. doi: 10.1007/s40273-014-0164-8

Guo Zihao, Capital Medical University. (2018, July 20).  New system for GERD diagnosis and treatment (EAISMLP). Identification No. NCT03600974. Retrieved from https://clinicaltrials.gov/ct2/show/study/NCT03600974

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Yamasaki, T., Hemond, C., Eisa, M., Ganocy, S., & Fass, R. (2018). The Changing Epidemiology of Gastroesophageal Reflux Disease: Are Patients Getting Younger? Journal of Neurogastroenterology and Motility, 24(4), 559–569. doi:10.5056/jnm18140