Gastroesophagel disease and liver cirrhosis

Gastroesophageal Reflux Disease (GERD)

Etiology and Pathophysiology
? Gastric contents enter esophagus causing inflammation; may cause a
precancerous condition (Barrett’s esophagus)
? Secondary to ?lower esophageal sphincter (LES) tone, obesity, hiatal
hernia, pregnancy
Signs and Symptoms
? Heartburn (pyrosis), hoarseness, wheezing, dysphagia
? Esophageal pH shows acidity, endoscopy or barium swallow reveal tissue
damage
Treatment
? Proton pump inhibitors, H2 receptor blockers, antacids, cholinergics
? Surgery to tighten esophageal fundus
Hiatal Hernia
Etiology and Pathophysiology
? Part of stomach slides upward into thoracic cavity; may cause reflux,
obstruction, hemorrhage
? Secondary to obesity, congenital weakness, pregnancy, female gender
Signs and Symptoms
? May be asymptomatic, evident in barium swallow
? Sense of fullness, regurgitation, pyrosis, dysphagia, nocturnal dyspnea
Treatment
? Paraesophageal hernias may require emergency surgery to ?restricted
blood flow
? See GERD
Nursing Care for Hiatal Hernia and GERD
? Monitor S&S; support weight control
? Teach patient to have small, frequent, low-fat meals; drink fluids between
meals; and remain upright 1hr after meals
? Teach patient to ?HOB to prevent nighttime distress
? Advise patient to avoid tight belts and waistlines and to avoid chocolate, caffeine, alcohol, and peppermint, which ?LES tone
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Liver cirrhosis

Etiology and Pathophysiology

? Fibrous scar tissue and fat accumulate in liver ?hepatomegaly and portal hypertension. Results in esophageal varices, hemorrhoids, obstructive jaundice and ascites
? ?Liver function ???metabolism ???ammonia (a metabolized protein by-product) ??encephalopathy.

Signs and Symptoms
? ?Liver enzymes (AST, ALT, LDH, GGT), jaundice, hepatomegaly
? ?Albumin, ?bilirubin, ?globulins, ?ammonia, ?PT
? Ascites, GI varices, edema secondary to ?albumin and ?aldosterone,
which causes retention of Na and H2O
? Confusion, agitation, flapping hand tremors (asterixis)
? Liver biopsy to confirm diagnosis














Types of cirrhosis:
1. Lannec s Cirrhosis caused by:
• Nutritional deficiencies.
• Exposure to alcohol.
• Exposure to toxins.
The liver enlarges (knobby) then shrinking.
It can be reversed if the case is corrected early.
2. Post necrotic Cirrhosis:
It is a complication of hepatitis, there is massive liver cell necrosis.
3. Biliary Cirrhosis
It is also called obstructive or idiopathic cirrhosis. It develops as a result of obstruction to bile flow.
4. Cardiac Cirrhosis:
It follows sever right side heart failure.
Venous congestion and hypoxia leads to necrosis of the liver cells.
Signs and Symptoms:
I. Mild Symptoms
1. Slight weight loss.
2. Unexplained fever.
3. Fatigue.
4. Abdominal pain described as heavy feeling in the right upper quadrant or epigastruim due to: stretching of the liver capsule , spasm of the Biliary ducts, and intermittent vascular spasm
5. Dull hearing in the right upper abdomen on percussion.
6. Liver is palpable below the right rib margin.


Complications:
1- Portal Hypertension:
The diseased liver changes obstruct the flow of incoming blood to back up in the portal system. It causes collateral vessels to develop (in an attempt to reduce this high pressure, reduce plasma volume and lymphatic flow) in the esophagus, anterior abdominal wall, and rectum.

2- Esophageal Varices:
They are distended, engorged tortuous vessels in the esophagus. They are fragile and bleed easily.
Factors may help in the bleed:
? Irritation due to alcohol.
? Swallowing of poorly masticated food or coarse food.
? Acid regurgitation from the stomach.
? Increased intra abdominal pressure due to vomiting, coughing, heavy lifting, staining at stool.
3- Peripheral Edema: Result from
? decreased colloidal osmotic pressure from impaired liver synthesis of albumin and
? increased portocaval pressure from portal hypertension
4-Ascites:
It is an accumulation of fluid in the peritoneal cavity.
Factors can contribute development of ascites with cirrhosis:
? Portal hypertension and the resulting increase in capillary pressure and obstruction in venous blood flow.
? Leaking of lymph fluid.
? Low serum albumin levels from impairment of liver synthesis of albumin due to decreased serum colloidal oncotic pressure.
? Increased aldoesterone levels stimulated by decreased renal blood flow and impairment of liver to metabolism of aldoesterone.
? Water retention due to reduction in renal vascular flow and excessive serum level of anti-diuretic hormone.
? Sodium& water retention, increased the intravascular fluid volume, and decreased the synthesis of albumin by the damaged liver all contributing to fluid moving from vascular system to the peritoneal space.


5-Hepatic Encephalopathy: (Hepatic Coma):
Inability of the liver to toxify ammonia which causes:
? Accumulation of ammonia in the blood.( Treated by frequent enema)
? Neurologic symptoms include:
a) Depression, apathy, irritability, memory loss, confusion, yawning, drowsiness, insomnia, agitation, slow and slurred speech, impaired judgment.
b) Hiccups, slow and deep respiration.
c) Hyperactive reflexes and positive Babinski s reflex.
? Declining level of consciousness.
? Hepatic coma develops include;
a) Disorientation as to person, place, time.
b) Changing in neuromuscular function: Asterixis (flapping tremor of the hands) or "liver flap". The patient is asked to hold the arm out with the hand held upward (dorsiflexed). With a few seconds the hands falls forward involuntary and then quickly returns to the dorsiflexed position.
c) Constructional apraxia: Deterioration of hand writing and inability to draw a simple star figure.
d) Hyperventilation, hypothermia, and grimacing and grasping reflexes.
e) Fetor hepaticus is a musty, sweet odor of the patient breath due to accumulation of digestive by products.



Treatment

? Vitamins (A, D, E, K, B), zinc, colchicine, K_ sparing diuretics
? Lactulose to ?ammonia; albumin
? Portal caval shunt, sclerotherapy or balloon tamponade for varices
? Paracentesis for ascites with dyspnea

Nursing management
? Monitor S&S, I&O, abdominal girth
? Teach to avoid alcohol
? Liver biopsy: Have patient hold breath during needle insertion; keep on
right side with pillow against insertion site. Assess for bleeding



? Paracentesis: Have patient void before and maintain an upright position
during procedure; after assess respiratory status, S&S of shock, persistent
leakage
? Balloon tamponade: Provide oral suction, maintain traction on gastric
balloon, monitor pressure of esophageal balloon










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