Inflammation Concept: GERD, Hiatal Hernia, Appendicitis

1. Inflammation Concept: GERD, Hiatal Hernia, Appendicitis Brunner ch. 35 & 38

2. Gastroesophageal Reflux Disease (GERD) (1014) • Backflow of gastric contents into esophagus. • Incidence increases with age • Affects infants as well but is referred to as GER

3. Etiology • Motility problems • Incompetent esophageal sphincter • Pyloric stenosis (more common in infants)

4. Assessment • Pyrosis • Dyspepsia • Odynophagia • Dysphagia • Acid regurgitation • Eructation • Hypersalivation (brash) • Globus sensation • Nocturnal cough • Wheezing • Hoarseness • Lying down or straining exacerbates symptoms • Diagnosed by barium swallow or endoscopy

5. Complications • Mucosal inflammation and breakdown • Sphincter incompetence • Chronic esophagitis, ulceration, and changes in the mucosa (Barrett’s epithelium). • Barrett’s is associated stricture and a 30% risk of cancer. Endoscopy shows red mucosa. Bx reveals dysplasia of the epithelium (looks more like intestinal than esophageal tissue)

6. Dietary Management • Small frequent meals • Fluids between meals • Low fat diet • Lose weight if indicated • Avoid spicy or acid foods, caffeine, carbonated drinks , chocolate, beer, mint, very hot or cold drinks

7. Other Suggestions • Sit up 1-2h after meals • Don’t eat 2h before bed • Reverse Trendelenberg with 6-8” blocks • Upper body elevated on pillows • Don’t strain or bend or wear tight clothing • Stop smoking

8. Pharmacologic Management • Antacids • H2 blockers (Pepcid, Zantac) • Proton pump inhibitors (Prilosec, Nexium). Increases incidence of stomach infection. • GI stimulants(Urecholine, Reglan). Watch for extrapyramidal side effects.

9. Hiatal Hernia (1012) • Herniation of stomach thru an enlarged esophageal opening in the diaphragm (1013). • Type 1 (sliding): upper stomach slides thru the opening into the chest cavity (90% ). • Type 2 (paraesophageal or rolling): upper stomach pushes up against diaphragm.

10. Contributing Factors • Age • Obesity • Congenital weakness • Trauma • Surgery • Pregnancy • Ascites • Heavy lifting

11. Assessment Type 1 Type 2 • 50% have dysphagia, dyspepsia, reflux • 50% asymptomatic • Dx by x-ray, barium swallow, fluoroscopy • Most complain of fullness or chest pain after eating • May be asymptomatic • Dx by x-ray, barium swallow, fluoroscopy

12. Complications • Hemorrhage • Obstruction • Strangulation

13. Management • Similar to GERD • Small frequent meals and may need dietary restrictions if reflux is present • No reclining for at least 1 hr after eating to prevent upward movement of the stomach • HOB up on 4-8” blocks • H2 blockers or proton pump inhibitors • If needed, Nissen fundoplication

14. Surgical Management If all else fails, Nissen fundoplication can be done by laparoscopic or open method. Repair of the hernia is done first then part of fundus is wrapped around distal esophagus and sutured.

15. Postop Care for Nissen Fundoplication • Physical assessment • HOB up 30 degrees • TCDB, IS • Analgesics • IVF • I&O • NPO with possible NGT (suction) unless laparoscopic • May have po after peristalsis returns (HCP decides) • No gassy foods, carbonated drinks, gum, straws • Ambulate!!

16. Appendicitis (1075) • Inflammation and infection of appendix • Appendix is attached to the cecum immediately past the ileocecal valve.

17. Etiology • Easily obstructed due to small lumen and inefficient emptying. • Caused by kinking, fecalith, tumor, or foreign body.

18. Assessment • Periumbilical pain moving to McBurney’s point (halfway between iliac crest and umbilicus) • +Rovsing’ssign (pressing on LLQ causes RLQ pain) • +Blumberg’s sign (rebound) • +Obturator muscle test (internal rotation of hip causes RLQ pain) • +Ileopsoas muscle test (hip flexion or hip abduction causes RLQ pain)

19. Assessment con’t • Guarding • Pain with digital rectal examination (DRE) • Low grade fever • Anorexia • NVD or constipation (NO LAXATIVES for anyone with RLQ pain) • Elevated WBC (usually 11-16,000) • +Abd x-ray or CT (shows RLQ density or bowel distention)

20. Complications • Ruptured appendix—pain becomes diffuse and generalized; WBC elevates from 16-40,000 • Peritonitis (inflammation of peritoneum) • Sepsis • Paralytic ileus

21. Plan of Care: Expected Outcomes • Patient will receive proper management of appendicitis • Patient’s pain will be controlled • Infectious and inflammatory processes will subside • Patient will experience full recovery without complications (wound infection, DVT, respiratory infection, etc.) • Patient will receive and understand all instructions

22. Surgical Management • Appendectomy: -Open or laparoscopic -Usually 24h stay -If perforated, several days with NG, IV, drains, possible open wound, IV meds -Pre and postop antibiotics

23. Nursing Management • Depends on whether OP or inpatient • Preoperatively, pt is assessed, IV with antibiotics, site is marked, laxatives & enemas are contraindicated • Postop VS per protocol • Pain control—IV to po • IVF and meds • Wound assessment and changes (if inpatient) • Advance DAT and activity • Pt education re: wound care, S&S infection, pain mgmt, activity restrictions, RTC time, when to call MD.

24. Plan of Care: Evaluation • Appendicitis has been resolved: • Appendectomy performed successfully • Infection and inflammation has subsided as evidenced by VS and WBC returned to normal levels • Patient’s pain is controlled • Patient had no complications • Patient received and understood all instructions