esophageal disorders

• Esophagus


  Muscular tube that carries food from the mouth to the stomach
• Esophagus

  • Its ability to transport food and fluid is facilitated by two sphincters
  • UES (Hypopharyngeal sphincters) located at the junction of the pharynx and the esophagus
  • LES (Gastroesophageal or cardiac sphincters) located at the junction of the esophagus and stomach
• Achalasia


  Absence or ineffective peristalsis of the distal (lower two thirds) esophagus accompanied by failure of the lower esophageal sphincter to relax in response to swallowing
• The pathology of achalasia is related to defective innervation of the myenteric plexus innervating the involuntary muscles of the esophagus
• Achalasia may progress slowly and occurs mostly in people 40 years and above
• Clinical Manifestations of Achalasia

  • Gradual onset of Dysphagia (solid and liquids)
  • Uncomfortable feeling that a bolus of food is caught in the esophagus
  • Food regurgitation, either spontaneous or intentionally done by the patient to relieve the discomfort
  • Non-cardiac Chest or Epigastric pain and heart burn may or may not be associated with eating
  • Weight loss
• Diagnostic Findings for Achalasia

  • X-ray- show esophageal dilation at the gastroesophageal junction
  • Barium swallow, Chest CT scan and endoscopy- shows dilation, decrease or absence of peristalsis and narrowing distal esophagus
  • Esophageal manometry confirms the diagnosis in which peristalsis, contraction amplitude and esophageal pressure is measured
  • Normal Esophageal pressure is (10-45mmHg) LES resting pressure
  • Elevated intraesophageal pressure is a common manometric finding in patients with achalasia, with a prevalence of 51.6%
• Nursing Assessment for Achalasia

  • Assess difficulty of swallowing, vomiting or reflux, heartburn and pain
• Nursing Diagnosis for Achalasia

  • Altered nutrition: Less than body requirement related to ss and sx
  • Pain r/t exposure of reflux and distention of the esophagus
• Nursing Interventions for Achalasia

  • Assess patient for discomfort, chest pain, regurgitations and cough
  • Eat in sitting upright position
  • Instruct the patient to eat SLOWLY and to drink fluids with meals
• Diet for Achalasia

  • Soft and Bland diet - are soft, not very spicy, and low in fiber.(cereals, such as oatmeal and cream of wheat, Fruit and vegetable juices, bread and pasta)
• Pharmacological Therapeutics for Achalasia

  • Oral calcium channel blockers and nitrates- used to decreased esophageal pressures and to improve swallowing
  • Botulinum toxin (Botox) injection into quadrants of the esophagus via endoscopy it inhibits the contraction of smooth muscle in the esophagus
• Complimentary/Conservative Therapy for Achalasia

  • Pneumatic Dilation to stretch the narrowed area of the esophagus
  • Moderate sedation via analgesic or tranquilizer may be given because the procedure is painful
• Surgical Interventions for Achalasia

  • Laparoscopic Heller myotomy / Esophagomyotomy - Cutting or opening of the esophageal muscle fibers, usually done laparoscopically with complete lower esophageal sphincter myotomy with anti reflux procedure or without
  • Peroral endoscopic myotomy (POEM) - allows myotomy of the lower esophageal sphincter (LES) but also of the esophageal body, where the hypertensive contractions often occur
• Pre-operative for Achalasia Surgery

  • Consent
  • NPO post- midnight
• Post-operative for Achalasia Surgery

  • Assess pain using PRS if surgical procedure was done
  • Assess signs of infection such as purulent discharge, swelling, redness and increase temperature
  • Analgesics as ordered
  • Assess effectiveness of pain medications
  • For the first week (7 days) after your Heller myotomy surgery, you can take a full or thick liquid diet such as milkshakes, puddings, soups and mashed potatoes
• Evaluation for Achalasia

  • Patient verbalizes no signs of difficulty of swallowing, vomiting or reflux, heartburn and chest pain
  • Absence of pain and infection post- operatively
• Esophageal Spasm


  Contractions of the esophagus are irregular, uncoordinated, and sometimes powerful, preventing food from reaching the stomach
• Types of Esophageal Spasm

  • Diffuse Esophageal Spasm - The spasms are normal in amplitude but uncoordinated, move quickly, or occur quickly at various places in the esophagus
  • Hypertensive Peristalsis/Nutcracker Esophagus - Peristalsis is coordinated, but the amplitude is very high
• Jackhammer esophagus/hypercontractile esophagus is an extreme form of Nutcracker Esophagus in which the contraction involve the entire esophagus over a period of time
• Nutcracker Esophagus is common among women and manifest in middle age
• Causes of Esophageal Spasm

  • unknown but stress, psychiatric disorders and psychotropic medications (lorazepam, alprazolam, Zoloft ,Prozac) can be a predisposing factor
• Assessment/Clinical Manifestations of Esophageal Spasm

  • Dysphagia, odynophygia (pain in swallowing) and Anterior chest pain
  • Dysphagia is more common in Diffuse Esophageal Spasm
• Diagnostic Tests for Esophageal Spasm

  • Esophageal Manometry - Measures the motility and internal pressures of the esophagus and can test irregular and high amplitude (plenty) spasms
  • Barium Esophagograpy - Shows simultaneous contractions of the esophagus having a "corkscrew" or "rosary bead" appearance
• Nursing Diagnosis for Esophageal Spasm

  • Altered Nutrition: Less than body requirement related to difficulty of swallowing or painful swallowing
  • Pain related to heartburn
• Nursing Interventions for Esophageal Spasm


  • Ensure emergency equipment is available (Suction, oxygen, face mask)
  • Patient is in Upright sitting position in a chair or High Fowlers with support on the back
  • Mouth care before meal and suction the mouth if secretions are present
  • Provide a calm environment. Remove distracters such as TV and radio
  • Diet: Small frequent feedings and Soft/ bland Diet- to reduce the esophageal pressure and irritation that lead to spasm
• Pharmacological Management for Esophageal Spasm

  • Calcium Channel blockers (Nifedipine (Procardia), Verapamil and Nitrates (Nitroglycerine) are primary treatment to reduce uncoordinated contraction
• Surgical Management for Esophageal Spasm

  • Surgical Myotomy - a minimally invasive procedure that opens the tight lower esophageal sphincter (the valve between the esophagus and the stomach) by performing a myotomy (cutting the thick muscle of the lower part of the esophagus and the upper part of the stomach) to relieve the dysphagia
• Gastroesophageal Reflux


  Back flow of gastric or duodenal contents into the esophagus, that causes symptoms or mucosal injury to the esophagus
• Lower Esophageal Sphincter (LES)


  A contracted smooth muscle surrounding the distal esophagus, innervated by vagal nerves and receives signals from different organs
• Gastroesophageal reflux is associated with an Incompetent LES due to defect in neural control may result in a dysfunctional LES with periods of transitory spontaneous relaxation. These periods of relaxation allows the gastric content to reflux back into the esophagus.
• Other Etiology of Gastroesophageal Reflux

  • Can be result of impaired gastric emptying from gastroparesis or partial gastric outlet obstruction
  • The acidity of gastric content and amount of time in contact with esophageal mucosa are related to the degree of mucosal damage resulting to inflammation and ulceration of the esophagus known as ESOPHAGITIS
  • May be cause pyloric stenosis, hiatal hernia and other motility disorder such as achalasia and esophageal spasm
• Clinical Manifestations of Gastroesophageal Reflux

  • Heartburn/Pyrosis- common symptom. It is often occurs 30-60 minutes after meals and with reclining position. Complaints of spontaneous reflux (regurgitation) of sour or bitter contents in the mouth
  • Forceful vomiting
  • Chest pain
  • Hoarseness
  • Chronic Cough
  • Bronchospasm
  • Odynophagia- substernal pain on swallowing
  • Dysphagia- less common symptom
• Diagnostic Tests for Gastroesophageal Reflux

  • Barium Swallow and Endoscopy- can visualize inflammation, lesions or erosions in the esophagus
  • Esophageal Manometry- measures the LES pressure and it determines if esophageal peristalsis is adequate
  • Ambulatory 12- 36 hour pH monitoring use to evaluate the degree or amount of acid reflux
  • Acid Perfusion (Bernstein Test)- onset of symptoms after ingestion of diluted Hydrochloric acid and saline considered positive
• Nursing Diagnosis for Gastroesophageal Reflux


  • Altered Nutrition, Fluid and Electrolyte Imbalance, Risk for Aspiration
• Nursing Interventions for Gastroesophageal Reflux

  • Raised the HOB at least 30 degrees to prevent gastric reflux
  • Bland,(small frequent feedings, bread, pasta, cereal) and Low fat, High protein diet
  • Don't lie down 3-4 hours after eating
  • Avoid caffeine. tobacco, beer, milk, foods containing peppermint and carbonated beverages (soda, champagne, sparkling wine), garlic, onion, citrus juices, colas, and tomato products (tomato sauce)
  • Avoid overeating- causes LES relaxation due to food overload in the stomach
  • Avoid non irritating foods
• Ambulatory 12- 36 hour pH monitoring


  Use to evaluate the degree or amount of acid reflux
• Acid Perfusion (Bernstein Test)


  Onset of symptoms after ingestion of diluted Hydrochloric acid and saline considered positive, differentiates between cardiac and non-cardiac chest pain
• NURSING DIAGNOSIS

  • Altered Nutrition
  • Fluid and Electrolyte Imbalance
  • Risk for Aspiration
• Phase 1: Lifestyle Changes

  1. Raise HOB at least 30 degrees

  2. Bland, small frequent feedings, bread, pasta, cereal, low fat, high protein

  3. Don't lie down 3-4 hours after eating

  4. Avoid caffeine, tobacco, beer, milk, foods containing peppermint and carbonated beverages, garlic, onion, citrus juices, colas, and tomato products

  5. Avoid overeating

  6. Avoid non irritating foods

  7. Avoid tight fitting clothes

  8. Avoid stress

  9. Alcohol and Smoking cessation

  10. Weight control if obese

  11. Drink water 30-60 ml q 30 minutes/hr to flush the acid in the esophagus