This document discusses gastroesophageal reflux disease (GERD). It defines GERD as a chronic condition caused by prolonged reflux of gastric contents into the esophagus, potentially causing esophagitis. It describes the anatomy and physiology related to GERD, including the lower esophageal sphincter. Risk factors include hiatal hernia, obesity, smoking, diet, medications and certain diseases. Diagnosis involves history, physical exam, barium swallow, endoscopy and pH monitoring. Treatment includes lifestyle changes, antacids, H2 blockers, PPIs, surgery and endoscopic procedures. Complications can include esophagitis, stricture, Barrett's esophagus and adenocarc

1. MS.MUTHU RAJATHI, M.SC (N)
ASST., PROFESSOR
DEPARTMENT OF MEDICAL SURGICAL NURSING
GANGA INSTITUTE OF HEALTH SCIENCES
COIMBATORE

2. GASTRO ESOPHAGEAL
REFLUX DISEASE

3. INTRODUCTION
• Common chronic disorder of gastro intestinal
system
• Small amount of gastric acid reflux is common for
adults and children.
• Earlier times, the older adults are high risk of
developing GERD. Nowdays due to poor dietary and
physical activity patter, adolescents and early adults
also affected by GERD.

4. SIGNIFICANT ANATOMY &
PHYSIOLOGY
 Esophagus is a mucus lined muscular tube to
carry the food materials to the stomach.
 Gastric acid helps in digestion process.
 Lower esophageal sphincter (LES) controls the
passage of food materials from the esophagus to
the stomach.
 Abnormal opening of LES will leads to reflux of
gastric acid.

5. SIGNIFICANT ANATOMY &
PHYSIOLOGY

6. LOWER ESOPHAGEAL SPHICTER
 Intrinsic distal
esophageal muscles
Tonically contracted–
muscular sling fibers of the
gastric cardia.
Diaphragmatic cura–
transmitted pressure of the
abdominal cavity

7. DEFINITION
Gastro esophageal reflux disease is a
chronic and relapsing condition in which
prolonged reflux of hydrochloric acid, pepsin
and bile salts into esophagus, oral cavity and
respiratory system that leads to esophagitis.
The pathological consequences of
involuntary passages of gastric content into
the esopahgus.

8. DEFINITION
Esophageal
mucosal damage
produced by
abnormal reflux
of gastric
contents into
esophagus.

9. INCIDENCE AND PREVALENCE
• The prevalence rate of GERD in India is 8% - 20% of
population.
• Age : Older adults are commonly affected. Incidence
of late adolescents & young adults also high in
number.
• Sex: Except pregnant mothers, both the sex are
equally affected.

10. CLASSIFICATION
PHYSIOLOGICAL GERD PATHOLOGICAL GERD
Post prandial period ---
Asymptomatic With symptoms
No mucosal injury Mucosal injury present
Short lived Long term illness
No nocturnal symptoms Nocturnal symptoms are
present.

11. CLASSIFICATION
• Motility problem
affecting lower
esophageal
sphincter.
PRIMARY
GERD
• External forces
causing abnormal
relaxation of LES.
EG: Food
SECONDARY
GERD

12. GRADING OF GERD
• One or more mucosal breaks no longer than 5
mm, no extends between the tops of the
mucosal fold
A
• One or more mucosal breaks more than 5 mm
long, no extends between the tops of two
mucosal folds
B
• Mucosal breaks that extend between the tops
of two or more mucosal folds, but are not
circumferential.
C
• One or more circumferential mucosal breaks
D

13. CAUSES AND RISK FACTORS
Motor abnormality
• IMPAIRED LES
TONE
• TRANSIENT LES
RELAXATION
DRUGS :
Anti cholinergics
Calcium channel
blockers
Oral contraceptives
Estrogen
Nitrates
FOOD :
Chocolates
Pepper
Garlic & onion
Fatty foods
Life style factors :
Smoking
Alcohol
obesity
Influenced
by

14. CAUSES AND RISK FACTORS
DISRUPTION OF
ANATOMICAL
BARRIERS
Large Hiatal Hernia
Relaxed LES sphincter
Caused
by
IMPAIRED
ESOPHAGEAL
CLEARANCE
Decreased salivation
secondary to ageing process.
IMPAIRED
MUCOSAL
RESISTANCE
Repeated exposure of
physiological reflux can lead to
mucosal damage.

15. RISK FACTORS
 Eating a heavy meal and lying on back or
bending over at the waist
 Snacking close to bedtime
 Eating certain foods, such as citrus, tomato,
chocolate, mint, garlic, onions, or spicy or
fatty foods
 Drinking certain beverages, such as alcohol,
carbonated drinks, coffee, or tea
 Being pregnant

16. RISK FACTORS –ASSOCIATED DISEASE
CONDITIONS
 Barrett's esophagus
 Scleroderma
 Asthma & COPD
 Diabetes mellitus
 Celiac disease
 Hormone replacement therapy

17. PATHOPHYSIOLOGY – DUE TO HIATAL
HERNIA
Esophageal
sphincter lies
above the
diaphragm
Excessive
pressure on the
LES due to
reduced
diaphragm
Relaxation of
LES
Reflux of
stomach acid
into the stomach
GERD

18. PATHOPHYSIOLOGY – DUE TO HIATAL
HERNIA
Esophageal
sphincter lies
above the
diaphragm
Excessive
pressure on the
LES due to
reduced
diaphragm
Relaxation of
LES
Reflux of
stomach acid
into the stomach
GERD

19. PATHOPHYSIOLOGY – DUE TO HIATAL
HERNIA

20. PATHOPHYSIOLOGY – DUE TO OBESITY
Increased intra
abdominal
pressure
Abnormal
pressure on LES
Backflow of
gastric contents
into esophagus
Irritation &
Erosion of
esophageal
mucosa
GERD &
Inflammation
of esophagus
Esophagitis

21. PATHOPHYSIOLOGY – DUE TO OBESITY

22. CLINICAL MANIFESTATIONS
ESOPHAGEAL
• Heart Burn
• Dysphagia
• Odynophagia
• Regurgitation
• Bleching
EXTRA ESOPHAGEAL
• Cough
• Wheezing
• Sore throat
• Globus sensation
• Epigastric pain
• Non cardiac chest pain
• Hyper salivation (Water Brash)
• Pharyngitis

23. CLINICAL MANIFESTATIONS
• Alarming symptoms
– Dysphagia
– early satiety
– GI bleeding
– odynophagia
– Vomiting
– unexplained weight loss
– Iron deficiency anemia
– choking
– continual pain

24. DIAGNOSTIC EVALUATION

25. DIAGNOSTIC EVALUATION
• HISTORY COLLECTION:
– Genetic influences
– Dietary pattern – type of food, meal time, activities
immediately after meal
– Medication history
– History of presenting symptoms
• Duration
• Aggravating/ alleviating factors

26. DIAGNOSTIC EVALUATION
• PHYSICAL EXAMINATION:
– Weight loss
– Dysphagia
– Heart burn
• BARIUM SWALLOW TEST :
• Rule out the presence of hiatal hernia,
esophagitis

27. DIAGNOSTIC EVALUATION
• ENDOSCOPY:
– In case of alarming symptoms, immediate
indication for endoscopy.
– Identify the grade of GERD .

28. DIAGNOSTIC EVALUATION
• ESOPHAGO
GASTRO
DUODENOSCOPY:
Allows for
detection, stratification,
and management of
esophageal
manifestations or
complications of
GERD.

29. PHYSIOLOGICAL STUDY : 24 HOURS PH
MONTIORING :
– Accepted standard for establishing or excluding
presence of GERD for those patients who do not
have mucosal changes

30. ESOPHAGEAL MANOMETRY
Assess LES pressure, location and relaxation
Assist placement of 24 hr. Ph catheter
Assess peristalsis - Prior to antireflux surgery

31. MANAGEMENT- PROTOCOL

32. MANAGEMENT – FIRST LINE THERAPY
ANTACIDS
H2 RECEPTOR
ANTAGONIST
PROTON PUMP
INHIBITOR
Decrease acid
secretion by inhibiting
the H2 receptor at the
parietal cell of the
stomach.
EG : cimetidine,
ranitidine, and
famotidine
Antacids neutralize
gastric acid and are
preferred for the
short-term relief of
GERD symptoms.
Bond and deactivate
hf,k+-atpase, or proton
pumps, by crossing
parietal cell membranes
and accumulating in
secretory canaliculi.
E.G : omeprazole

33. MANAGEMENT – SECOND LINE DRUGS
Promote gastric
emptying and
reduce the risk of
gastric acid reflux.
Eg : Domperidone
CYTOPROTECTIVE
DRUGS
CHOLINERGIC
DRUGS
PROKINETIC
DRUGS
Enhances the motility of
lower esophageal
sphincter.
EG : pyridostigmine
Non absorable
components of
drugs absorbed into
ulcerated tissue &
acid exposoure
tissue which favors
the healing
process.
Eg : Sucraflate.

34. MANAGEMENT – DRUG THERAPY
20%
50%
80%
100%
DRUG RESPONSE
ANTACIDS
H2RA
PPIs
COMBINATION

35. MANAGEMENT – LIFE STYLE
MODIFICATIONS
• Weight reduction if overweight
• Avoid clothing that is tight around the waist
• Modify diet
– Eat more frequent but smaller meals
– Avoid fatty/fried food, peppermint, chocolate,
alcohol, carbonated beverages, coffee and tea,
onions, garlic.
– Stop smoking
• Elevate head of bed 4-6 inches
• Avoid eating within 2-3 hours of bedtime

36. MANAGEMENT- SURGICAL OPTIONS

37. MANAGEMENT- SURGICAL OPTIONS

38. MANAGEMENT- ENDOSCOPIC
THERAPY
• Rapid radiofrequency energy delivered to
the LES
– Stretta procedure
• Suture ligation of the cardia
– Endoscopic fundoplication
• Submucosal implantation of inert material in
the region of the lower esophageal sphincter
– Enteryx

39. NISSEN FUNDOPLICATION
• The gastric fundus (upper part) of the stomach is wrapped,
around the lower end of the esophagus and stitched in
place, reinforcing the closing function of the lower
esophageal sphincter.

40. ENDOSCOPIC RADIOFREQUENCY
THERAPY

41. ENDOLUMINAL GASTROPLICATION

42. SURGICAL IMPLANTATION OF RINGS

43. COMPLICATIONS
• Erosive esophagitis
– Acid irritation and inflammation can injure the esophagus
over time, creating a condition known as erosive
esophagitis.
• Stricture
– Abnormal narrowing of the esophageal lumen
• Barrett's esophagus
– Abnormal (metaplastic) change in the mucosal cells lining
the lower portion of the esophagus.
• Adenocarcinoma

44. NURSING MANAGEMENT
• Acute pain in epigastric region related to
inflammatory process in the esophagus as evidenced
by pain scale score.
• Imbalanced nutrition less than body requirement
related to difficulty in swallowing secondary to
esophageal irritation as evidenced by verbalization.
• Chest discomfort related to irritation of esophagus
secondary to backflow of gastric contents as
evidenced by verbalization & refusal to take food.

45. NURSING MANAGEMENT
• Nausea related delayed gastric emptying as
evidenced by verbalization.
• Risk for bleeding related to esophageal mucosal
damage.
• Risk for aspiration related to recurrent gastric
regurgitation.
• Ineffective airway clearance related to backflow of
gastric content into upper respiratory tract as
evidenced by cough and verbalization of hoarseness
of voice.

46. NURSING MEASURES
• Assess the pain level of the patient.
• Maintain I/O chart strictly.
• Avoid exposure to mucusoal irritants.
• Check for the symptoms of bleeding.
• Give health education on life style modification
measures.
• Fluid replacement therapy if needed.
• Follow the chart of foods to be added/ avoided list.

47. NURSING MEASURES
• Elevate the head end of the bed to 45 degree.
• Follow the measures in the bed time meals.
– Do not take food before 2 – 3 hrs of bed time
– Avoid snacks at bed time.
– Avoid fatty / oily foods.
– Avoid caffeinated beverages.

48. SOURCES
• Brunner & suddharth’s, TB of Medical
Surgical Nursing
• Lewis, TB of Medical Surgical Nursing .
• Joyce.m. black, TB of Medical Surgical
Nursing .
• www. Gerdhelp.com
• www. Pubmed.com