Plan Of Care/ Treatment
GASTROESOPHAGEAL REFLUX DISEASE
Iriabel Nepravishta
Chamberlain College of Nursing
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What’s Covered
Commonly prescribed drugs for Gastroesophageal Reflux Disease
Barriers to practice i.e. issues related to GERD and use of pharmacologic treatment (Potential issues related to cultural diversity and healthcare literacy)
Expected outcomes for medication management
Expectations for follow up care.
History of Present Illness (HPI)
The patient is a 42- year old male who has a history of “ a burning sensation in his chest”, the patient also has regurgitation symptoms occasionally, the patient also describes that the pain increases when he lies down.
The patient also has early satiety and postprandial fullness.
Amongst these episodes the patient also describes that he experiences bilateral back pains.
The patient has also experienced instances of heart burn, and dysphagia
The less common symptoms of GERD include
Hypersalivation
Nausea
Coughing
Chest pain
Odynophagia (Gibson, 2017)
On the other hand most patients with GERD portray these symptoms
Heart burn
Regurgitation
Dysphagia (Gibson, 2017)
From the above history of the patient, the results are very convincing of an existing case of Gastroesophageal Reflux Disease.
A lot of patients complain of substernal pain that is upward moving. This pain is most of the time aggravated by meals and lying down. The pain ceases once the patient assumes a sitting position (Woo, Robinson, n.d) More signs and symptoms include a sore throat, halitosis, and hoarseness in the patient (Woo, Robinson, n.d). Dysphagia stipulates that the patient has long standing GERD. Under dysphagia, the patient may need to use lots of fluid and multiple swallows to ensure the safe passage of food into the stomach (Woo, Robinson, n.d)
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Physical Examination of the patient
The patients vital signs revealed the following
Temperature, 99.1 F, weight 190lbs ( height 5’ 3), BP 132/78 mm Hg, respirations 18.
The patient showed some lingual erosion on the teeth, his tonsils were enlarged, and the oropharynx was moist and pink.
The patient’s cardiac state was regular without any gallops or murmurs.
The patient showed 5/5 motor strength.
The patient’s abdomen produced normal active bowel sounds.
Signs and symptoms alone may not be sufficient to diagnose a patient with GERD (Woo, Robinson, n.d).
The American College of Gastroenterology (ACG) suggests some guidelines on the diagnosis of patients with GERD (Woo, Robinson, n.d)
ACG recommends the use of endoscopy in elder patients (Woo, Robinson, n.d).
Alarm symptoms in a patient according to ACG include vomiting, anemia, weight loss, hematemesis, and dysphagia (Woo, Robinson, n.d).
These above symptoms warrant a diagnosis with GERD (Woo, Robinson, n.d).
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Description of the disease
GERD is also know as acid reflux disease.
The disease causes a burning sensation in the chest of the patient.
Symptoms like regurgitation and heartburn lead to the diagnosis of the patient with GERD.
Persistent GERD causes damage to the esophagus.
Acid reflux disease is in relation to the taste of acid back to the mouth. Famously known as heartburn (Woo, Robinson, n.d).
Presumptive diagnosis is made based on heartburn, or regurgitation.
GERD also presents itself as epigastric pain, a chronic cough, or chest pain (Woo, Robinson, n.d).
Damage to the esophagus is as a result of irritation to the esophageal mucosa (Woo, Robinson, n.d).
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Pathophysiology
GERD is a resultant of chyme reflux into the esophagus from the stomach.
The lower esophageal sphincter is crucial to the maintenance of the barrier between the stomach and the esophagus.
Gastric acid separates in the stomach by forming layers that lie over the ingested food
Regurgitation causes this highly acidic gastric acid to move back into the esophagus of the patient.
The Lower esophageal sphincter in patients with GERD is not as stiff in its resisting tone as opposed to a healthy person (Woo, Robinson, n.d).
The LES in GERD patients relaxes after 1 to 2 hours upon eating (Woo, Robinson, n.d).
This relaxation of the LES is what causes regurgitation of food back into the esophagus (Woo, Robinson, n.d).
The highly acidic gastric acid into the esophagus is what causes irritation, heartburn, or chest pains in the patient (Woo, Robinson, n.d).
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Signs and symptoms of GERD
The less common symptoms of GERD include
Hypersalivation
Nausea
Coughing
Chest pain
Odynophagia (Gibson, 2017)
On the other hand most patients with GERD portray these symptoms
Heart burn
Regurgitation
Dysphagia (Gibson, 2017)
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Commonly prescribed drugs for GERD
Medics recommend over the counter drug for patients to treat GERD.
These medications help the stomach muscles empty food from the stomach or stop acid production in the belly.
For patients with heartburn medics recommend the use of antacids like Maalox, Pepcid, tumbs, Rolaids, Riopan, and Alka-Seltzer (Gibson, 2017).
Antacids help to relieve heartburn and mild GERD (Gibson, 2017).
These antacids use combinations of calcium, magnesium, and aluminum with bicarbonate or hydroxide to neutralize the stomach acid (Gibson, 2017).
These are some of the fore front drugs recommended by practitioners (Gibson, 2017)
Antacids have side effects like aluminum may lead to constipation while magnesium is know to cause diarrhea (Gibson, 2017)
These side effects can be solved by combining both aluminum and magnesium salts (Gibson, 2017)
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Commonly prescribed drugs for GERD with their trade names
Foaming agents. An example is Gaviscon (Aluminum hydroxide). Foaming agents do not change the acidity of the belly.
H2 blockers e.g. famotidine (Pepcid), nizatidine (Tazac), ranitidine, and cimetidine act by reducing acid production in the stomach.
Prescribed proton pump inhibitors e.g. iansoprazole (Prevacid), pantoprazole (Protonix), rabeprazole, and omeprazole.
Prokinetics e.g. metoclopramide (Reglan), and bathenachol (Urecholine) (Gibson, 2017) these serve better when combined with acid suppressors (Woo, Robinson, n.d)
Foaming agents act by coating the stomach with foam. This foam functions like a barrier that protects the esophagus and prevents reflux (Gibson, 2017)
Proton pump prescription drugs tend to be more effective than H2 blockers (Gibson, 2017)
Proton pump inhibitors relieve GERD symptoms and also heal the esophageal lining (Ness-Jensen, et al, 2016).
Prokinetics help the stomach empty much faster and also strengthens LES (Gibson, 2017)
Prokinetics are reactive in the digestive tract by helping the digestive muscles and strengthening them (Gibson, 2017)
However, side effects from prokinetics include fatigue, anxiety, depression, sleepiness, and motor movements (Gibson, 2017)
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Mechanism of action
Drugs used to decrease mucosal exposure i.e. sucralfate (Carafate) and misoprostol (Cytotec) act as a band aid that covers erosive sites e.g. ulcers.
Drugs that improve peristalsis e.g. prokinetics act by improving LES tone.
Drugs that reduce the amount of acid produced e.g. histamine and PPIs operate on the parietal cells and decrease the amount of acid produced.
Misoprostol acts by improving the production of cytoprotective mucus (Woo, Robinson, n.d)
PPIs are the preferred first line therapy for GERD (Woo, Robinson, n.d)
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Barriers to practice i.e. issues related to GERD and use of pharmacologic treatment (adverse effects)
Metoclopramide when used in children can lead to adverse reactions like dystonia, somnolence, insomnia, and restlessness.
Prokinetics and metoclopramide in older adults can lead to central nervous system toxicity (Woo, Robinson, n.d).
Additionally, Prokinetics and metoclopramide also lead to congestive heart failure, hypokalemia, or renal failure (Woo, Robinson, n.d)
Espghan GERD guidelines advice that prokinetics should not be use in children ( Woo, Robinson, n.d)
There are some adverse effects from these medication that do not cease upon drug withdrawal (Woo, Robinson, n.d)
For example Espghan GERD guidelines advice that prokinetics should not be used in children (Woo, Robinson, n.d)
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Barriers to practice i.e. issues related to GERD and use of pharmacologic treatment
Contributing factors that lead to the advancement of GERD can all be treated
These drugs can be used to diminish the amount of acid in the stomach/chyme, lead to the betterment of peristalsis, decrease exposure to mucosa, and increase LES tone among others.
There are certain foods that catalyse Gastroesophageal Reflux disease. These foods inhibit the use of pharmacologic treatment of the disease.
The risk factors related to GERD disease include
Obesity
Pregnancy
Hiatal hemia
Smoking
Consuming drinks with caffeine
Consuming foods with chocolate, onions, spicy foods, garlic, citrus fruits, mint flavors etc. (Gibson, 2017)
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Barriers to practice i.e. issues related to GERD and use of pharmacologic treatment
There are other medications that also inhibit the use of pharmacologic treatment in patients with GERD.
Patients under other medication for other diseases like seasickness, asthma, high blood pressure, heart disease, insomnia, anxiety, Parkinson’s disease, menstrual bleeding, and birth control should notify the doctor before getting prescribed or using GERD medication drugs.
These medications below are risk factors for GERD
Bronchodilators used in the treatment of asthma
Calcium channel blockers for high blood pressure
Beta blockers for high blood pressure and heart disease
Anticholinergic used for seasickness
Dopamine-active medication drugs used to treat Parkinson’s disease
Tricyclic antidepressants
Sedatives used to handle anxiety and insomnia
Progestin used in birth control and menstrual bleeding (Gibson, 2017)
These medications could accelerate cases o heartburn and such cases should be reported to the doctor.
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Expected outcomes for medication management
The use of medication like H2 blockers, foaming agents, proton pump inhibitors, and Prokinetics are aimed at the following goals.
Eliminate or reduce the symptoms of GERD
Manage complications like stricture, esophageal carcinoma, or Barrett’s esophagus
To heal esophageal lesions
To prevent cases of relapse
Expected outcomes for medication management
The first step of treatment of Gastroesophageal Reflux disease involves lifestyle modification and the use of over the counter drugs like antacids.
For patients with mild to severe GERD, the use of PPIs is the first line of treatment
PPI therapy continues for the majority of patients for up to 8 weeks (Woo, Robinson, n.d).
Patients who are unresponsive to PPIs should be referred to a gastroenterology specialist (Woo, Robinson, n.d).
Other patients try using over the counter drugs before the visit the doctor (Woo, Robinson, n.d).
Sometimes over the counter drugs tend to be sufficient in treating mild cases of GERD (Woo, Robinson, n.d).
Over the counter drugs are efficient in treating mild cases of GERD where there are no instances of corrosive disease (Woo, Robinson, n.d).
Maintenance therapy should be prescribed to patients who have recurring cases of GERD even after PPIs are prescribed (Woo, Robinson, n.d).
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Expectations for follow up care
Follow up care includes a patient being reassessed in 6 months to 12 months.
For patients who have reoccurring instances of GERD, maintenance therapy is recommended (Woo, Robinson, n.d).
The purpose of such reassessment and follow up care is to find out whether the patient can be weaned off the therapy (Woo, Robinson, n.d).
Maintenance therapy is also used in patients with Barrett’s esophagitis or erosive esophagitis (Woo, Robinson, n.d).
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Questions
What are the symptoms of GERD
Regurgitation of food
Abdominal muscle contractions
Sore throat
All of the above
Which are the triggering factors of GERD
The body position of the patient
Smoking
Pregnancy
Obesity
Questions
3) Which of the following are lifestyle changes needed for the treatment of GERD?
quit smoking
Eating small and frequent meals
Wearing loose fitting clothes
All of the above
Questions
4) Which of these contribute to GERD
Obesity
Pregnancy
Smoking
All of the above
Questions
5) When is atypical GERD prevalent?
During pregnancy
when symptoms are positional
Individuals who are H. pylori-negative
Patients with negative cardiac evaluation and atypical chest pains
References
Woo, T. M., Robinson, M. V. Pharmacotherapeutics For Advanced Practice Nurse Prescribers. [VitalSource Bookshelf]. Retrieved from https://online.vitalsource.com/#/books/9780803658110 /
Gibson M. C., (2017) Gastroesophageal reflux disease (patient information) https://www.wikidoc.org/index.php/Gastroesophageal_reflux_disease_(patient_information)# Diagnosis
Ness-Jensen, E., Hveem, K., El-Serag, H., & Lagergren, J. (2016). Lifestyle intervention in gastroesophageal reflux disease. Clinical gastroenterology and hepatology, 14(2), 175-182.
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