Med-Surg - Gastrointestinal System, part 4: Dysphagia, GERD, Hiatal Hernia
by Cathy Parkes November 20, 2021 Updated: August 09, 2023 6 min read
Hi. I'm Cathy, with Level Up RN. In this video, I am going to begin my coverage of gastrointestinal disorders. Specifically, I will be talking about dysphagia, GERD or gastro esophageal reflux disease, as well as a hiatal hernia. At the end of the video, I'm going to give you guys a little quiz to test your knowledge of some of the key points I'll be covering in this video. So definitely stay tuned for that. And if you have our Level Up RN medical surgical nursing flashcards, definitely pull those out so you can follow along with me.
So let's start with dysphagia, which is difficulty swallowing.
This can be caused by a structural abnormality. It can also be caused by a disorder that affects the nerves or muscles that are involved in swallowing.
So examples of disorders that can result in dysphagia include a stroke, cerebral palsy, Parkinson's and ALS.
Signs and symptoms of dysphagia include coughing and frequent clearing of the throat, difficulty with eating or drinking and aspiration pneumonia. So aspiration pneumonia is where food or liquid ends up down in the airways, so in the lungs, and that causes inflammation and infection.
So in terms of diagnosis, when we suspect that a patient has difficulty swallowing, we need to make sure a referral is sent to the speech language pathologist. This is the member of the interdisciplinary team that is going to come and evaluate the patient's swallowing ability and make recommendations in terms of diet. So after the speech language pathologist sees the patient, they will recommend one of four levels of a diet.
So level one dysphagia diet means that all of the patients food is going to be pureed and their liquids are going to be thickened. So in the hospital, we have some pre-thickened liquids that you can give the patient. But if the patient wants something like coffee, you have to mix this special thickening powder in with the coffee to thicken those liquids, which makes it easier to swallow. And any day that I work with a patient who has to consume thickened liquids, I'm just so grateful that I can swallow effectively, and I don't have to drink that stuff because it is not appetizing. Anyway, so that level one is the more serious dysphagia. And again, it's all pureed.
If we have level two or three, that's going to include soft and moist foods. In addition to a speech language pathologist evaluation, other diagnostic tools include a barium swallow test as well as an EGD to try to identify any kind of structural abnormalities.
In terms of treatment, like I mentioned, someone with dysphagia will need to have their liquids thickened, and the dysphagia diet will include either pureed or soft and moist foods. In addition, we want to make sure the head of the bed is up when the patient is consuming food, because when they're laying down, it makes aspiration much more likely.
We also need to teach our patient to tuck their chin against their chest when they are swallowing, so they need to tuck it like that. They should not be extending their neck back when they're swallowing. It should be tucked, so provide that guidance. And then in worst case scenarios, if the patient cannot safely consume food because of their dysphagia, they may require a feeding tube.
Next, let's talk about GERD, which is gastro esophageal reflux disease. So this is where the gastric contents which contain just of enzymes back flows into the esophagus, and it causes pain and mucosal damage, so it leads to esophagitis, which is inflammation of the esophagus.
It can also lead to something called Barrett's esophagus. So when the cells in the esophagus are repeatedly exposed to that stomach acid, they mutate and that turns into Barrett's esophagus. And that places the patient at high risk for esophageal cancer.
So the pathophysiology behind GERD is that we often have excessive relaxation or weakness of that lower esophageal sphincter. That sphincter is supposed to prevent stomach contents from back flowing into the esophagus, but that sphincter is not working correctly, then GERD can occur.
Risk factors associated with GERD include obesity, smoking, alcohol use, older age, pregnancy, ascitis, and hiatal hernia, which we're going to talk about after GERD.
In terms of signs and symptoms, the patient will exhibit dyspepsia, which is a fancy name for indigestion. In addition, they may complain of throat irritation, a bitter taste. They will have burning pain in their esophagus that will feel better when they're sitting up and be worse when they're laying down, which makes sense, right? If you're sitting upright, then gravity is working for you and those stomach contents are more likely to stay in the stomach. If you're laying down, then it makes it much easier for those stomach contents to back flow into the esophagus. In addition, a chronic cough is common in patients who have GERD.
We can diagnose GERD with a number of diagnostic procedures and tests, including an EGD and upper GI series, so that's a barium swallow, as well as esophageal PH monitoring and something called esophageal manometry. This is where we test the function of that lower esophageal sphincter.
In terms of treatment, a number of medications can be very effective in the treatment of GERD. This includes antacids, H2-receptor antagonist, PPIs and prokinetic agents. And I have a whole video dedicated to those classes of medications in my pharmacology playlist, so definitely check that out.
In terms of surgical interventions, if medications and lifestyle modifications are unsuccessful, the patient can undergo a Nissen fundoplication. And it sounds like fun multiplication, but it's really not fun. It's a pretty invasive surgical procedure where the top of the stomach so the fundus is wrapped around the esophagus.
In terms of patient teaching, we want to advise our patient to avoid fatty, fried, and spicy foods. They should avoid citrus foods as well as caffeine. They should try to eat smaller meals, so maybe like five smaller meals as opposed to three large meals. They should remain upright after meals, so that's going to make it less likely for reflux to occur. They should avoid eating right before bedtime. Again, because if they eat and then go to bed, laying down is going to make it more likely that reflex occurs. We want them to avoid tight fitting clothing because if they have like a tight belt on, for example, it will make it harder for the GI contents to work their way through the GI system and make it more likely that they can reflux. They should lose weight if applicable. Quit smoking, if applicable, reduce their alcohol intake and then elevate the head of their bed at home so they can do this with blocks. Or they can get one of the more fancy beds where you can lift the head of the bed, kind of like a hospital bed.
The last disorder I want to cover in this video is a hiatal hernia. This is where we have protrusion of the stomach through the diaphragm into the thoracic cavity. So normally, we have our thoracic cavity, our diaphragm, our abdominal cavity below that. There's a hole in the diaphragm to allow the esophagus to go through it. That's called a hiatus.
And with this disorder, a portion of the stomach comes through that opening, the hiatus, and it can cause a number of symptoms. It can also become caught and become strangulated. And if this occurs, this blocks blood flow to this organ and can result in necrosis.
So signs and symptoms of a hiatal hernia include heartburn, dysphagia and chest pain after meals.
Diagnosis can be done with a barium swallow study as well as an EGD.
Treatment includes the same GERD medications that we previously talked about, so antacids, PPIs, prokinetic agents, etc.
And then the surgery is the same, too. If the patient is requiring a surgical intervention, if meds and lifestyle changes are unsuccessful, a fundoplication surgery would be indicated. Again, that's where the top of the stomach, the fundus is wrapped around the esophagus.
And then in terms of patient teaching, we're going to teach the patient all the same things as we did with GERD. So we want to avoid spicy, fatty foods when avoid caffeine and citrus, eat smaller meals, remain upright after meals, etc.
All right. It's quiz time. I have three questions for you. First question a swallow evaluation is performed by what interdisciplinary team member? The answer is a speech language pathologist. Question number two, with GERD, pain is increased when sitting up and decreased when laying down. True or false? The answer is false. It will feel better when the patient is sitting up and feel worse when they are laying down. Question number three, what surgical procedure can be used for severe GERD or a hiatal hernia? The answer is a Nissen fundoplication.
All right. I hope this video has been helpful. If so, be sure to like it and leave me a comment. Take care and good luck with studying.
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