CHAPTER 54 Care of Patients with Esophageal Problems

Chart 54-1 Key Features Gastroesophageal Reflux Disease

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Diagnostic Assessment: Esophageal Tumors

A barium swallow study with fluoroscopy may be the first diagnostic test requested to evaluate dysphagia. The definitive diagnosis of esophageal cancer is made by esophageal ultrasound (EUS) with fine needle aspiration to examine the tumor tissue. An esophagogastroduodenoscopy (EGD) may also be performed to inspect the esophagus and obtain tissue specimens for cell studies and disease staging. A complete cancer staging workup is performed to determine the extent of the disease and plan appropriate therapy. Positron emission tomography (PET) may identify metastatic disease with more accuracy than a CT scan. PET can also help evaluate response to chemotherapy

Diagnostic Assessment: GERD

A definitive diagnostic test for GERD does not exist. Patients may drink a solution and then have x-rays performed as part of a barium swallow, which shows hiatal hernias, strictures, and other structural or anatomic problems. Upper endoscopy (also called esophagogastroduodenoscopy [EGD]) involves insertion of an endoscope (a flexible plastic tube equipped with a light and lens) down the throat, which allows the health care provider to see the esophagus. A pH monitoring examination is the most accurate method of diagnosing GERD. This involves either (1) placing a small catheter through the nose into the distal esophagus or (2) temporarily attaching a small capsule to the wall of the esophagus during an upper endoscopy (the 48-hour Bravo esophageal ph test). The patient is asked to keep a diary of activities and symptoms over 24 to 48 hours (depending on diagnostic method), and the pH is continuously monitored. Esophageal manometry, or motility testing, may be performed when the diagnosis is uncertain. Water-filled catheters are inserted in the patient's nose or mouth and slowly withdrawn while measurements of LES pressure and peristalsis are recorded. When used alone, manometry is not sensitive or specific enough to establish a diagnosis of GERD. A Gastric Emptying Study can also be done while a patient is in the radiology/nuclear medicine department. He or she is given a meal mixed with radiolucent dye, and imaging is performed to determine how well the stomach empties.

Other Therapies: Esophageal Tumors

A key to success with targeted therapy is that the cancer cells must overexpress the targeted protein. Thus each patient's cancer cells are first examined for the overexpression to determine if targeted therapy is appropriate and which drug to use. Trastuzumab (Herceptin) is a commonly used drug that is used for patients whose esophageal cancer tests positive for an excess of the HER2 protein. Photodynamic therapy (PDT) is used as a palliative treatment for patients with advanced esophageal cancer who are not candidates for surgery. It may be used also as a cure for patients who have very small, localized tumors. The patient is injected with porfimer sodium (Photofrin), a light-sensitive drug that collects in cancer cells. Two days after the injection, a fiberoptic probe with a light at the tip is threaded into the esophagus through an endoscope. The light activates the Photofrin, destroying only cancer cells. The side effects of Photofrin are rare but include nausea, fever, and constipation. Remind the patient to avoid exposure to sunlight for 1 to 3 months. Sunglasses and protective clothing that covers all exposed body areas are essential. Teach the patient to follow a clear liquid diet for 3 to 5 days after the procedure and advance to full liquids as tolerated. Esophageal dilation is usually performed on an ambulatory care basis. Dilators are used to tear soft tissue, thereby widening the esophageal lumen (opening). In most cases, malignant tumors can be dilated safely, but perforation remains a significant risk. Large metal stents may be used to keep the esophagus open. To reduce the risk for endocarditis, antibiotics are given. The treatment is repeated as often as needed to preserve the patient's ability to swallow. Prolonged stent embedment into benign esophageal tissue can cause ulceration, bleeding, fistula, dysphagia, and formation of new stricture if the stent is not removed. Laser therapy or electrocoagulation using endoscopy may be performed as a palliative measure. Both of these methods destroy some cancer cells and reduce tumor size to improve swallowing.

Preoperative Care: Esophageal Tumors

Advise the patient to stop smoking 2 to 4 weeks before surgery to enhance pulmonary function. Patient preparation may include 5 days to 2 to 3 weeks of nutrition support to decrease the risk for postoperative complications. Teach the patient and family to monitor the patient's weight and intake and output. A preoperative evaluation may be required to treat dental disease. Teach the patient to use meticulous oral care 4 times daily to decrease the risk for postoperative infection. Teach the patient about: • The number and sites of all incisions and drains • The placement of a jejunostomy tube for initial enteral feedings • The need for chest tubes if the pleural space is entered • The purpose of the nasogastric tube • The need for IV infusion Teach the patient about routines for turning, coughing, deep breathing, and chest physiotherapy. Emphasize the crucial nature of postoperative respiratory care. If colon interposition (resecting a piece of colon and creating an esophagus) is planned, the patient also has a complete bowel preparation before surgery. Encourage the patient to talk about personal feelings and fears, and involve the family or significant others in all preoperative teaching and discussions.

Critical Rescue

After esophageal surgery, carefully assess for fever, fluid accumulation, signs of inflammation, and symptoms of early shock (e.g., tachycardia, tachypnea). Report any of these findings to the surgeon or Rapid Response Team immediately!

Postoperative Care: Hiatal Hernia

Are at risk for bleeding and infection, although these problems are not common. The nursing care priority is to observe for these complications and provide health teaching. Postoperative care after conventional open repair closely follows that required after any esophageal surgery. Incentive spirometry and deep breathing are routinely used. Adequate pain control with analgesics is essential for postoperative deep breathing and coughing. The patient having the conventional surgery usually has a large-bore (diameter) nasogastric (NG) tube to prevent the fundoplication wrap from becoming too tight around the esophagus. Initially the NG drainage should be dark brown with old blood. The drainage should become normal yellowish green within the first 8 hours after surgery. Check the NG tube every 4 to 8 hours for proper placement. Monitor patency of the NG tube to keep the stomach decompressed. This prevents retching or vomiting, which can strain or rupture the stomach sutures. The NG tube is irritating. Therefore provide frequent oral hygiene. Assess the patient's hydration status regularly, including accurate measures of intake and output. Adequate fluid replacement helps thin respiratory secretions. The patient may begin clear fluids when peristalsis is re-established or in an effort to stimulate peristalsis. Some foods, especially caffeinated or carbonated beverages and alcohol, are either restricted or eliminated. The food storage area of the stomach is reduced by the surgery, and meals need to be both smaller and more frequent. Carefully supervise the first oral feedings because temporary dysphagia is common. Continuous dysphagia usually indicates that the fundoplication is too tight, and dilation may be required. Gas bloat syndrome, in which patients are unable to voluntarily eructate (belch). The syndrome is usually temporary but may persist. Teach the patient to avoid drinking carbonated beverages and to avoid eating gas-producing foods (especially high-fat foods), chewing gum, and drinking with a straw. Aerophagia (air swallowing) from attempting to reverse or clear acid reflux. Teach them to relax consciously before and after meals, to eat and drink slowly, and to chew all food thoroughly. Air in the stomach that cannot be removed by belching can be extremely uncomfortable. Frequent position changes and ambulation are often effective interventions for eliminating air from the GI tract. If gas pain is still present, patients are taught to take simethicone.

Assessment: GERD

Ask the patient about a history of heartburn or atypical chest pain associated with the reflux of GI contents. Ask whether he or she has been newly diagnosed with asthma or has experienced morning hoarseness or pneumonia, because these symptoms may indicate severe reflux reaching the pharynx or mouth or pulmonary aspiration.

Assessment: Hiatal Hernia

Ask the patient if he or she has heartburn, regurgitation (backward flow of food into the throat), pain, dysphagia (difficulty swallowing), and eructation (belching). Assess general physical appearance and nutrition status. Note the location, onset, duration, and quality of pain, as well as factors that relieve it or make it worse. Auscultate the lungs because pulmonary symptoms similar to asthma may be triggered by episodes of aspiration. Symptoms resulting from hiatal hernia typically worsen after a meal or when the patient is in a supine position. In those with rolling hernias, assess for symptoms related to stretching or displacement of thoracic contents by the hernia. Patients may report a feeling of fullness after eating or have breathlessness or a feeling of suffocation. May experience chest pain associated with reflux that mimics angina. The barium swallow study with fluoroscopy is the most specific diagnostic test for identifying hiatal hernia. Rolling hernias are usually clearly visible, and sliding hernias can often be observed when the patient moves through a series of positions that increase intra-abdominal pressure. To visualize sliding hernias, an esophagogastroduodenoscopy (EGD) may be performed.

History: Esophageal Tumors

Assess for risk factors such as gender, history of alcohol consumption, tobacco use, dietary habits, and other esophageal problems (e.g., dysphagia, reflux). Men, regardless of race or ethnicity, have higher incidence and mortality rates. Ask the patient about consumption of smoked and/or pickled foods, changes in appetite, changes in taste, or weight loss.

Physical Assessment/Clinical Manifestations: Esophageal Tumors

By the time the tumor causes symptoms, it usually has spread extensively. Dysphagia (difficulty swallowing) is the most common symptom of esophageal cancer, but it may not be present until the esophageal opening has gotten much smaller. Dysphagia is persistent and progressive when stricture (narrowing) occurs. Late in the disease, even saliva can cause choking. Patients usually report a sensation of food sticking in the throat or in the substernal area. Weight loss often accompanies dysphagia and can exceed 20 pounds over several months. Odynophagia (painful swallowing) is reported by many patients as a steady, dull, substernal pain that may radiate. It occurs most often when the patient drinks cold liquids. Assess for regurgitation, vomiting, halitosis (foul breath), and chronic hiccups, which often accompany advanced disease. In most patients, pulmonary problems develop. Assess for chronic cough, increased secretions, and a history of recent infections. Tumors in the upper esophagus may involve the larynx and thus cause hoarseness.

Esophageal Tumors

Can be benign, most are malignant (cancerous) and the majority arise from the epithelium. Squamous cell carcinomas of the esophagus are located in the upper two thirds of the esophagus. Adenocarcinomas are more commonly found in the distal third and at the gastroesophageal junction and are now the most common type of esophageal cancer. Esophageal tumors grow rapidly. The esophageal mucosa is richly supplied with lymph tissue, there is early spread of tumors to lymph nodes. More than half of esophageal cancers metastasize (spread throughout the body). Primary risk factors are smoking and obesity. In addition to these primary risk factors, malnutrition, untreated gastroesophageal reflux disease (GERD), and excessive alcohol intake are also associated with esophageal cancer. Barrett's esophagus results from exposure to acid and pepsin, which leads to the replacement of normal distal squamous mucosa with columnar epithelium. Appears to be linked to high levels of nitrosamines (which are found in pickled and fermented foods) and foods high in nitrate. Diets that are chronically deficient in fresh fruits and vegetables have also been implicated.

Genetic/Genomic Considerations

Certain genetic factors may have a role in the development of esophageal cancers. It is thought that these cancers result from mutations in tumor suppressor genes. Tumor suppressor genes are normal genes that control cell growth and division. When this type of gene is mutated and does not work properly, cells are unable to stop growing and dividing and tumors can result. Overexpression and mutations of the Tp53, Tp16, and Tp17 tumor suppressor genes have been found in people with esophageal cancer. In addition, the presence of the mutated Tp53 gene may be an indication of advanced disease, especially in patients with adenocarcinomas. Overexpression of cyclin D1, a protein that promotes cell growth and division, has also been found in patients with esophageal squamous cell cancers. Cyclins are products of oncogenes, which are normal genes involved in cell division and are controlled by suppressor genes. Prolonged exposure to carcinogens, such as tobacco, can cause oncogenes to escape the control of suppressor genes, leading to overexpression of cyclins and uncontrolled cell growth (cancer).

Esophageal Diverticula

Diverticula are sacs resulting from the herniation of esophageal mucosa and submucosa into surrounding tissue. They may develop anywhere along the length of the esophagus. Zenker's diverticula, the most common form. This type occurs most often in older adults. Patients report dysphagia (difficulty swallowing), regurgitation (reflux), nocturnal cough, and halitosis (bad breath). They can also be at risk for perforation. Diagnosed most often by esophagogastroduodenoscopy (EGD). Nutrition therapy and positioning are the major interventions for controlling symptoms related to diverticula. Semisoft foods and smaller meals are often best tolerated and may reduce or relieve the symptoms of pressure and reflux. Nocturnal reflux associated with diverticula is managed by teaching the patient to sleep with the head of the bed elevated and to avoid the supine position for at least 2 hours after eating. Advise the patient to avoid vigorous exercise after meals. Teach him or her to avoid restrictive clothing and frequent stooping or bending. Surgical management is aimed at removing the diverticula. Postoperatively, the patient is NPO status for several days to promote healing. During that period, the patient receives IV fluids for hydration and tube feedings; after that, he or she is given oral fluid and food. Provide pain relief measures, and monitor for complications such as bleeding or perforation. A nasogastric (NG) tube is placed during surgery for decompression and is not irrigated or repositioned unless specifically requested by the surgeon. Community-based care includes teaching the patient and family about: • Nutrition therapy • Positioning guidelines to prevent reflux • Warning signs of complications, such as bleeding or infection

Physical Assessment/Clinical Manifestations: GERD

Dyspepsia, also known as "indigestion," and regurgitation are the main symptoms of GERD. May include abdominal discomfort, feeling uncomfortably full, nausea, and burping. Patients may delay seeking treatment. The symptoms typically worsen when the patient bends over, strains, or lies down. If the indigestion is severe, the pain may radiate to the neck or jaw or may be referred to the back. Pain generally occurs after each meal and lasts for 20 minutes to 2 hours. May worsen when the patient lies down. Drinking fluids, taking antacids, or maintaining an upright posture usually provides prompt relief. Regurgitation (backward flow into the throat) of food particles or fluids is common. Risk for aspiration is increased if regurgitation occurs when the patient is lying down. Even if the patient is in an upright position, he or she may experience warm fluid traveling up the throat without nausea. If the fluid reaches the level of the pharynx, he or she notes a sour or bitter taste. A reflex salivary hypersecretion known as water brash occurs in response to reflux. Water brash is different from regurgitation. Ask the patient if he or she experiences eructation (belching), flatulence (gas), and bloating after eating; these are other common manifestations. Nausea and vomiting rarely occur. Assess for crackles in the lung. Long-term regurgitation may experience coughing, hoarseness, or wheezing at night. Chronic GERD can cause dysphagia (difficulty swallowing). Odynophagia (painful swallowing) can also occur with chronic GERD, but it is rare. Other manifestations include atypical chest pain, symptoms of asthma, and chronic cough that occurs mostly at night or when the patient is lying down. Cough and symptoms of asthma occur when refluxed acid is spilled over into the tracheobronchial tree. Atypical chest pain is thought to be caused by stimulation of pain receptors in the esophageal wall and by esophageal spasm. This type of chest pain can mimic angina.

Surgical Management: Esophageal Tumors

Esophagectomy is the removal of all or part of the esophagus. An esophagogastrostomy involves the removal of part of the esophagus and proximal stomach. With early-stage cancer, a laparoscopic-assisted minimally invasive esophagectomy (MIE) may be performed. However, most patients require the conventional open surgery because of tumor size and metastasis by the time they are diagnosed with the disease.

Nonsurgical Management: GERD

Relieve symptoms, treat esophagitis, and prevent complications such as strictures or Barrett's esophagus. For most patients, GERD can be controlled by nutrition therapy, lifestyle changes, and drug therapy. The most important role of the nurse is patient and family education. Teach the patient that GERD is a chronic disorder that requires ongoing management. The disease should be treated more aggressively in older adults.

Gastroesophageal Reflux Disease

GERD is the most common upper GI disorder in the United States. It occurs most often in middle-aged and older adults but can affect people of any age. Gastroesophageal reflux (GER) occurs as a result of backward flow of stomach contents into the esophagus. GERD is the chronic and more serious condition that arises from persistent GER. A person with acute symptoms of inflammation is often described as having mild or severe reflux esophagitis. A 1.2-inch (3-cm) segment at the proximal end of the esophagus is called the upper esophageal sphincter (UES), whereas another small portion at the gastroesophageal junction (near the cardiac sphincter) is called the lower esophageal sphincter (LES). Sphincter function is also supported by the acute angle (angle of His) that is formed as the esophagus enters the stomach. The most common cause of GERD is excessive relaxation of the LES, which allows the reflux of gastric contents. Patients who are overweight or obese are at highest risk for development of GERD. Nighttime reflux tends to cause prolonged exposure of the esophagus to acid because lying supine decreases peristalsis and the benefit of gravity. Hiatal hernias also increase the risk for development of GERD due to the creation of increased intra-abdominal pressure. Helicobacter pylori may contribute to reflux. Hyperemia (increased blood flow) and erosion (ulceration) occur in the esophagus in response to the chronic inflammation. The body may substitute Barrett's epithelium (columnar epithelium) for the normal squamous cell epithelium of the lower esophagus. Although this new tissue is more resistant to acid and therefore supports esophageal healing, it is considered premalignant and is associated with an increased risk for cancer. The fibrosis and scarring that accompany the healing process can produce esophageal stricture (narrowing of the esophageal opening). The stricture leads to progressive difficulty swallowing. Uncontrolled esophageal reflux also increases risk for other complications such as asthma, laryngitis, dental decay, cardiac disease, and serious concerns for hemorrhage and aspiration pneumonia. Patients who have a nasogastric tube also have decreased esophageal sphincter function. The tube keeps the cardiac sphincter open and allows acidic contents from the stomach to enter the esophagus. Other factors that increase intra-abdominal and intragastric pressure (e.g., pregnancy, wearing tight belts or girdles, bending over, ascites) overcome the gastroesophageal pressure gradient. Many patients with obstructive sleep apnea report frequent episodes of GERD.

Hiatal Hernia

Hiatal hernias, also called diaphragmatic hernias, involve the protrusion of the stomach through the esophageal hiatus of the diaphragm into the chest. Sliding hernias (which are most common) and paraesophageal (rolling) hernias. The esophagogastric junction and a portion of the fundus of the stomach slide upward through the esophageal hiatus into the chest, usually as a result of weakening of the diaphragm (Fig. 54-1). Although volvulus (twisting of a GI structure) and obstruction do occur rarely, the major concern for a sliding hernia is the development of esophageal reflux. Positions that favor reflux, such as bending or lying supine. Coughing, obesity, and ascites also increase reflux symptoms. With rolling hernias, also known as paraesophageal hernias, the gastroesophageal junction remains in its normal intra-abdominal location but the fundus (and possibly portions of the stomach's greater curvature) rolls through the esophageal hiatus and into the chest beside the esophagus. Reflux is not usually present, but the risks for volvulus (twisting of a GI structure), obstruction (blockage), and strangulation (stricture) are high. The development of iron deficiency anemia is common because slow bleeding from venous obstruction causes the gastric mucosa to become engorged and ooze.

Preoperative Care: Hiatal Hernia

If the surgery is not urgent, the surgeon instructs patients who are overweight to lose weight before surgery. They are also advised to quit or significantly reduce smoking. As part of preoperative teaching, reinforce the surgeon's instructions and prepare the patient for what to expect after surgery.

Drug Therapy: GERD

Includes three major types—antacids, histamine blockers, and proton pump inhibitors. These drugs, which are also used for peptic ulcer disease, have one or more of these functions: • Inhibit gastric acid secretion • Accelerate gastric emptying • Protect the gastric mucosa Antacids may be effective for occasional episodes of heartburn, but their length of action is too short and their nighttime effectiveness is minimal. Antacids containing aluminum hydroxide or magnesium hydroxide may be used. Teach the patient to take the antacid 1 hour before and 2 to 3 hours after each meal. Gaviscon, a combination of alginic acid and sodium bicarbonate, is often a very effective drug for GERD. It forms thick foam that floats on top of the gastric contents and theoretically decreases the incidence of reflux. Histamine receptor antagonists, commonly called histamine blockers, such as famotidine (Pepcid) and ranitidine (Zantac), decrease acid, are long acting, have fewer side effects, and allow less-frequent dosing. Proton pump inhibitors (PPIs), such as omeprazole (Prilosec), rabeprazole (AcipHex), pantoprazole (Protonix), and esomeprazole (Nexium), are the main treatment for more severe GERD.

Operative Procedures: Hiatal Hernia

Involves reinforcement of the lower esophageal sphincter (LES) by fundoplication. The surgeon wraps a portion of the stomach fundus around the distal esophagus to anchor it and reinforce the LES. Laparoscopic Nissen fundoplication (LNF) is a minimally invasive surgery commonly used for hiatal hernia repair. For the trans-thoracic surgical approach, teach the patient about chest tubes. Inform the patient that a nasogastric tube will be inserted during surgery and will remain in place for several days. Oral intake is started gradually with clear liquids after peristalsis is re-established or to stimulate peristalsis. Instruct the patient how to deep breathe and use the incentive spirometer. The high incision makes deep breathing extremely painful. Teach the patient about postoperative pain, and assure him or her that adequate postoperative analgesic will be given. In paraesophageal repair (a laparoscopic surgery), several 1/2 inch incisions are made in the abdomen, through which the hernia is closed and is typically reinforced using mesh. Less commonly, a conventional open procedure is used in which the surgeon uses a high trans-thoracic approach that requires a large chest incision.

Surgical Management: GERD

Laparoscopic Nissen fundoplication (LNF) is a minimally invasive surgery (MIS) and is the standard surgical approach for treatment of severe GERD. Patients who have surgery are encouraged to continue following the basic anti-reflux regimen of antacids and nutrition therapy because the rate of recurrence is high.

Key Points: Physiological Integrity

• For patients with GERD, teach the importance of strict adherence to anti-reflux agents in preventing esophageal damage (see Chapter 55, Chart 55-3). • Be aware that laparoscopic Nissen fundoplication (LNF) and laparoscopic paraesophageal repairs are common surgical procedures for patients with GERD and hiatal hernia. • Assess for complications and provide postoperative care for patients having the LNF procedure, as described in Chart 54-6. • Be sure to frequently monitor the nutrition status of the patient with esophageal cancer. • Teach the patient having open conventional esophageal surgery about incisions, drains, and jejunostomy tube placement before he or she undergoes surgery for esophageal cancer. • For the patient with a nasogastric (NG) tube, check the NG tube every 4 to 8 hours for proper placement and anchorage; follow guidelines as outlined in Chart 54-8. • Assess the patient after esophageal surgery for pulmonary and cardiac complications of surgery, and report changes to the health care provider. • Assess patients for key features of esophageal tumors as listed in Chart 54-7.

Operative Procedures: Esophageal Tumors

MIE procedure, the surgeon makes four or five small incisions in the chest and abdomen using a video-assisted thoracoscope and laparoscope. The lower esophagus and gastric fundus are removed. The remaining portion of the esophagus is then anastomosed (reconnected) to the stomach. For most patients, the surgeon performs an open subtotal or total esophagectomy because tumors are often large and involve distant lymph nodes. For a subtotal (partial) removal, the diseased portion of the esophagus is removed and the cervical portion is anastomosed (connected) to the stomach (Fig. 54-3). A pyloromyotomy is done by cutting and suturing the pylorus. Finally, a jejunostomy tube may be placed for postoperative enteral feeding. For patients with early-stage tumors of the lower third of the esophagus, a transhiatal esophagectomy is the preferred surgical approach. The surgery is performed through an upper midline cervical incision. With this approach, the pleural space is not entered, reducing respiratory complications. For patients with tumors in the upper esophagus, a radical neck dissection and laryngectomy may also be needed if the disease has spread to the larynx. The surgeon may perform a colon interposition when the tumor involves the stomach or the stomach is otherwise unsuitable for anastomosis. A section of right or left colon is removed and brought up into the thorax to substitute for the esophagus.

Action Alert

Monitor for manifestations of fluid volume overload, particularly in older patients and in those who have undergone lymph node dissection. Assess for edema, crackles in the lungs, and increased jugular venous pressure. In the immediate postoperative phase, the patient is often admitted to the intensive care unit. Critical care nurses assess hemodynamic parameters such as cardiac output, cardiac index, and systemic vascular resistance every 2 hours to monitor for myocardial ischemia. Observe for atrial fibrillation that results from irritation of the vagus nerve during surgery, and manage according to agency protocol.

Nonpharmacologic Interventions: GERD

Nutrition therapy is used to relieve symptoms in patients with relatively mild GERD. Ask about the patient's basic meal patterns and food preferences. Coordinate with the dietitian, patient, and family. Teach the patient to limit or eliminate foods that decrease LES pressure and that irritate inflamed tissue, causing heartburn, such as peppermint, chocolate, alcohol, fatty foods (especially fried), caffeine, and carbonated beverages. The patient should also restrict spicy and acidic foods (e.g., orange juice, tomatoes). Teach patients that smoking and alcohol use should also be avoided. Remind the patient to eat four to six small meals each day rather than three large ones. Encourage patients to avoid eating at least 3 hours before going to bed. Advise the patient to eat slowly and chew thoroughly to facilitate digestion and prevent eructation (belching). Teach the patient to elevate the head by 6 to 12 inches for sleep to prevent nighttime reflux. This can be done by placing blocks under the head of the bed or by using a large, wedge-style pillow instead. Teach the patient to sleep in the right side-lying position to promote oxygenation and frequent swallowing to clear the esophagus. Promote weight-loss strategies. Teach the patient to avoid wearing constrictive clothing, lifting heavy objects or straining, and working in a bent-over or stooped position. Obese patients often have obstructive sleep apnea, as well as GERD. Those who receive continuous positive airway pressure (CPAP) treatment report improved sleeping and decreased episodes of reflux. Some drugs lower LES pressure and cause reflux, such as oral contraceptives, anticholinergic agents, sedatives, NSAIDs (e.g., ibuprofen), nitrates, and calcium channel blockers.

Considerations for Older Adults

Older adults are at risk for developing severe complications associated with GERD due to age-related physiologic changes, medication side effects, and an increased prevalence of hiatal hernias (Solomon & Reynolds, 2012). Instead of heartburn associated with GERD, this population experiences more severe complications of the disease such as atypical chest pain; ear, nose, and throat infections; and pulmonary problems, such as aspiration pneumonia, sleep apnea, and asthma. Barrett's esophagus and esophageal erosions are also more common in older adults.

Home Care Management: Esophageal Tumors

Once the patient is discharged to home, ongoing respiratory care remains a priority. Give the patient and family instructions for ambulation and incentive spirometer use. Encourage the patient to be as active as possible and to avoid excessive bedrest because this can lead to complications of immobility. Teach the family to protect the patient from infection and to contact the health care provider immediately if signs of respiratory infection develop. Patients should stay away from people with infections and avoid large crowds.

TABLE 54-1 Factors Contributing to Decreased Lower Esophageal Sphincter Pressure

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Chart 54-2 Health Promotion and Lifestyle Changes to Control Reflux

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Chart 54-3 Postoperative Instructions for Patients Having Stretta Procedure

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Chart 54-4 Key Features Hiatal Hernias

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Chart 54-5 Postoperative Instructions for Patients Having Laparoscopic Nissen Fundoplication (LNF) or Paraesophageal Repair via Laparoscope

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Chart 54-6 Assessment of Postoperative Complications Related to Fundoplication Procedures

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Chart 54-7 Key Features Esophageal Tumors

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Chart 54-8 Managing the Patient with a Nasogastric Tube after Esophageal Surgery

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TABLE 54-2 Common Causes of Esophageal Perforation

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Community-Based Care: Hiatal Hernia

Patients undergoing one of the open surgical repairs require activity restrictions during the 3- to 6-week postoperative recovery period. For laparoscopic surgery, activity is typically restricted for a shorter time. Teach the patient and family about appropriate nutrition modifications. The use of stool softeners or bulk laxatives is recommended for the first postoperative weeks until healing is complete. Instruct the patient to avoid straining and to prevent constipation. Teach him or her to inspect the healing incision daily and to notify the health care provider if swelling, redness, tenderness, discharge, or fever occurs. Advise the patient to avoid contact with people with a respiratory infection and to contact the health care provider if symptoms of a cold or influenza develop. Continuous coughing can cause the incision or the fundoplication to dehisce ("break open"). Encourage the patient to eat smaller and more frequent meals. Instruct the patient to report reflux symptoms to the health care provider.

Self-Management Education: Esophageal Tumors

Remind the patient and family to wash their hands frequently, and teach them to inspect the incisions daily for redness, tenderness, swelling, odor, and discharge because proper wound healing is still a concern. Report a temperature greater than 101° F (38.3° C), or 100° F (37.8° C) for older adults, which may be a sign of infection. Prepare written instructions about the signs of anastomosis leakage. Teach the patient or family to immediately report to the health care provider the presence of fever and a swollen, painful neck incision. Encourage the patient to continue increasing oral feedings as tolerated. Remind him or her to eat small, frequent meals containing high-calorie, high-protein foods that are soft and easily swallowed. Teach the value of using supplemental milkshakes between meals, and instruct the patient to eat slowly. Teach the patient to monitor his or her weight at home and to report a weight loss of 5 pounds or more in 1 month. Emphasize remaining upright after meals. Emphasis is placed on maximizing quality of life. Realistic planning is important as the patient's condition eventually worsens, and the patient and family are assisted to plan for the future together. Assist family members in exploring formal and informal sources of support. Help the family or significant others arrange for hospice care.

Considerations for Older Adults

Research has also found that long-term use of proton pump inhibitors may increase the risk for hip fracture, especially in older adults. PPIs can interfere with calcium absorption and protein digestion and therefore reduce available calcium to bone tissue. Decreased calcium makes bones more brittle and likely to fracture, especially as people age.

Action Alert

Respiratory care is the highest postoperative priority for patients having an esophagectomy. For those who had traditional surgery, intubation with mechanical ventilation is needed for at least the first 16 to 24 hours. Pulmonary complications include atelectasis and pneumonia. The risk for postoperative pulmonary complications is increased in the patient who has received preoperative radiation. Once the patient is extubated, begin deep breathing, turning, and coughing every 1 to 2 hours. Assess the patient for decreased breath sounds and shortness of breath every 1 to 2 hours. Provide incisional support and adequate analgesia for effective coughing.

Endoscopic Therapies: GERD

The Stretta procedure, a nonsurgical method, can replace surgery for GERD when other measures are not effective. The physician applies radiofrequency (RF) energy through the endoscope using needles placed near the gastroesophageal junction. The RG energy decreases vagus nerve activity, thus reducing discomfort for the patient.

Postoperative Care: Esophageal Tumors

The advantages of MIE to open procedures, include: • Less blood loss during surgery; fewer blood transfusions • Decreased healing and recovery time • Decreased trauma to the body • No large incisions • Less postoperative pain • Shorter hospital stay (5 to 7 days rather than 7 to 10 days) Keep the patient in a semi-Fowler's or high-Fowler's position to support ventilation and prevent reflux. The health care provider prescribes prophylactic antibiotics and supplemental oxygen. Ensure the patency of the chest tube drainage system, and monitor for changes in the volume or color of the drainage. Cardiovascular complications, particularly hypotension during surgery, can occur as a result of pressure placed on the posterior heart and usually respond well to IV fluid. The patient with poor nutrition or prior radiation or chemotherapy is at risk for infection. Mediastinitis (inflammation of the mediastinum) resulting from an anastomotic leak can lead to fatal sepsis. Wound management is another major postoperative concern. Provide direct support to the incision during turning and coughing to prevent dehiscence. Wound infection can occur 4 to 5 days after surgery. Leakage from the site of anastomosis is a dreaded complication that can appear 2 to 10 days after surgery. If an anastomotic leak occurs, all oral intake is discontinued and is not resumed until the site of the leak has healed. A nasogastric (NG) tube is placed intraoperatively to decompress the stomach to prevent tension on the suture line. Monitor the NG tube. Do not irrigate or reposition the NG tube in patients who have undergone esophageal surgery unless requested by the surgeon! The initial nasogastric drainage is bloody but should change to a greenish yellow color by the end of the first postoperative day. The continued presence of blood may indicate internal bleeding at the suture line. Commonly, an antacid will be prescribed. Provide oral hygiene for the patient every 2 to 4 hours while the tube is in place, or delegate. After conventional surgery, on the second postoperative day, initial feedings usually begin through the jejunostomy tube (J tube). Do not aspirate for residual, because this increases the risk for mucosal tearing. Before beginning oral feedings, a cine-esophagram study is performed to detect any anastomotic leaks, strictures, or signs of aspiration. Place the patient in an upright position, and supervise all initial swallowing efforts. Teach the patient and/or family the importance of the patient eating six to eight small meals per day. Fluids should be taken between, rather than with, meals to prevent diarrhea. Diarrhea can occur 20 minutes to 2 hours after eating and can be managed with loperamide (Imodium) before meals. Thought to be the result of vagotomy syndrome, which develops as a result of interrupted vagal fibers to the abdominal organs during surgery

Psychosocial Assessment: Esophageal Tumors

The disease is accompanied by distressing symptoms and is often terminal. The fear of choking can place unusual stress, especially at mealtimes. The loss of pleasure and social aspects of eating may affect relationships with family and friends. Assess the patient's response to the diagnosis and prognosis. Ask about his or her usual coping strengths and resources. Assess the impact of the disease on the patient's usual daily activity routine. Determine the availability of support systems and the potential financial impact.

Nonsurgical Management: Hiatal Hernia

The health care provider typically recommends antacids and a proton-pump inhibitor such as lansoprazole (Prevacid), omeprazole (Prilosec), or esomeprazole (Nexium) in an attempt to control reflux and its symptoms. Nutrition therapy is also important and follows the guidelines discussed earlier.

Promoting Nutrition: Esophageal Tumors

The major concern for a patient with esophageal cancer is weight loss secondary to dysphagia. Therefore he or she is expected to maintain adequate nutrient intake and weight. Focus on treatments that remove or shrink the obstructive tumor. Methods to reduce the effects of treatment that can impact nutrition are also a priority. Surgery is the most definitive intervention. Nonsurgical treatment options for cancer of the esophagus that can assist in both disease and nutrition management include: • Nutrition therapy • Swallowing therapy • Chemotherapy • Radiation therapy • Chemoradiation • Targeted therapies • Photodynamic therapy • Esophageal dilation • Endoscopic therapies

Expected Outcomes: Esophageal Tumors

The major expected outcome is that the patient will be able to consume adequate nutrition and maintain a stable weight.

Action Alert

The most important role of the nurse in caring for a patient with a hiatal hernia is health teaching. Encourage the patient to avoid eating in the late evening and to avoid foods associated with reflux. Teach the patient and family that the patient should follow a restricted diet and should exercise regularly. Reducing body weight is beneficial because obesity increases intra-abdominal pressure and worsens both the hernia and the symptoms of reflux. Teach about positioning, including: • Sleep at night with the head of the bed elevated 6 inches • Remain upright for several hours after eating • Avoid straining or excessive vigorous exercise • Refrain from wearing clothing that is tight or constrictive around the abdomen

Analysis: Esophageal Tumors

The most specific common problem for patients with esophageal cancer is decreased nutrition intake related to impaired swallowing and possible metastasis. Many patients with cancer also have pain and are fearful because of the diagnosis

Action Alert

The primary focus of care after conventional surgery for a hiatal hernia repair is the prevention of respiratory complications. Elevate the head of the patient's bed at least 30 degrees to lower the diaphragm and promote lung expansion. Assist the patient out of bed and begin ambulation as soon as possible. Be sure to support the incision during coughing to reduce pain and to prevent excessive strain on the suture line, especially with obese patients.

Respond by:

• Providing semi-solid or thickened liquids if solid foods cannot be swallowed comfortably • Collaborating with the dietitian and occupational therapist (OT) for swallowing evaluation and training • Monitoring for aspiration of secretions or food • Teaching lifestyle changes, such as foods to avoid, smoking and alcohol cessation, weight reduction (if obese), and importance of drug therapy to control symptoms • Monitoring weight • Monitoring for increased dysphagia

Nutrition and Swallowing Therapy: Esophageal Tumors

The purpose of nutrition therapy is to administer food and fluids to support the patient who is malnourished or at high risk for becoming malnourished. Be sure the patient is weighed daily before breakfast on the same scale each day. To keep the esophagus patent, careful positioning is essential for a patient who is experiencing frequent reflux or who has tubes. Teach the patient to remain upright for several hours after meals and to avoid lying completely flat. Remind unlicensed assistive personnel (UAP) and other health care team members to keep the head of the bed elevated to a 30-degree angle or more. Semisoft foods and thickened liquids are preferred. Record the amount of food and fluid intake every day to monitor progress. Liquid nutrition supplements (e.g., Boost, Ensure) are used between feedings to increase caloric intake. Collaborate with the speech-language pathologist (SLP) to assist the patient with oral exercises to improve swallowing (swallowing therapy) and with the occupational therapist (OT) for feeding therapy. Ask the patient to suck on a lollipop to enhance tongue strength. Teach the patient to reach for food particles on the lips or chin using the tongue. In preparation for swallowing, remind the patient to position the head in forward flexion (chin tuck). Then tell him or her to place food at the back of the mouth. Monitor him or her for sealing of the lips and for tongue movements while eating. Check for pocketing of food in the cheeks

Chemotherapy and Radiation: Esophageal Tumors

The use of chemotherapy in the treatment of esophageal cancer has been only moderately effective. It can be given as a primary treatment if the patient is not a candidate for surgery. Chemotherapy is given in combination with radiation therapy to provide the patient the best chance of cure. The most commonly used paired chemotherapeutic agents for esophageal cancer are carboplatin and paclitaxel (Taxol) or cisplatin and 5-fluorouracil (5-FU). These drugs are often combined with radiation because they make the tumor cells more sensitive to radiation effects. Radiation therapy to manage esophageal cancer is only moderately effective and can be used alone or in combination with other treatments. Although high doses of radiation demonstrate the best results for tumor shrinkage, esophageal stricture or stenosis can result in many patients. Chemoradiation is a treatment for esophageal cancer that involves the use of chemotherapy at the same time as radiation therapy. One cycle of chemotherapy is given during the first week of radiation and another is delivered during the fifth week of radiation. Additional drug cycles are given after radiation therapy is complete.

Esophageal Trauma

Trauma may affect the esophagus directly, impairing swallowing and nutrition, or it may create problems in related structures such as the lungs or mediastinum. When excessive force is exerted on the esophageal mucosa, it may perforate or rupture, allowing the caustic acid secretions to enter the mediastinal cavity. These tears are associated with a high mortality rate related to shock, respiratory impairment, or sepsis. Chemical injury is usually a result of the accidental or intentional ingestion of caustic substances. Acid burns tend to affect the superficial mucosal lining. Alkaline substances cause deeper penetrating injuries. Additional problems may include aspiration pneumonia and hemorrhage. Esophageal strictures may develop. Assess for airway patency, breathing, chest pain, dysphagia, vomiting, and bleeding as the priorities for patient care. If the risk for extending the damage is not excessive, an endoscopic study may be requested to evaluate tears or perforation. A CT scan of the chest can be done to assess for the presence of mediastinal air. After the injury, keep the patient NPO to prevent further leakage of esophageal secretions. Esophageal and gastric suction can be used for drainage and to rest the esophagus. Esophageal rest is maintained for more than a week after injury to allow for initial healing of the mucosa. Total parenteral nutrition (TPN) is prescribed. To prevent sepsis, the health care provider prescribes broad-spectrum antibiotics. High-dose corticosteroids may be administered to suppress inflammation and prevent strictures (esophageal narrowing). In addition, opioid and non-opioid analgesics are prescribed for pain management. When caustic 1124burns involve the mouth, topical agents such as lidocaine (Xylocaine Viscous) may be used for analgesia and local anti-inflammatory action. If nonsurgical management is not effective in healing traumatized esophageal tissue, the patient may need surgery to remove the damaged tissue. Those with severe injuries may require resection.

Critical Rescue

When the patient with an esophageal tumor is eating or drinking, monitor for signs and symptoms of aspiration, such as choking or coughing. Food aspiration can cause airway obstruction, pneumonia, or both, especially in older adults. In coordination with the SLP, teach family members and caregivers how to feed the patient, if needed. Teach them how to monitor for aspiration and implement appropriate measures if choking occurs.

Key Points: Psychosocial Integrity

• Allow the patient the opportunity to express fear or anxiety regarding the diagnosis of esophageal cancer and related treatment regimen of surgery, chemotherapy, and radiation. Patient-Centered Care image • Explain all procedures, restrictions, drug therapy, and follow-up care to the patient and family. • Refer the patient or family members to psychological counseling, hospice, pastoral care, and the case manager as needed.

Perform and interpret focused physical findings, including:

• Assessing ability to chew and swallow food • Assessing chest pain (dyspepsia) for quality, location, and intensity • Assessing body weight change • Auscultating lungs • Assessing readiness to learn

Key Points: Safe and Effective Care Environment

• Consult with the dietitian, patient, and family regarding nutrition restrictions for patients with GERD. • Collaborate with the health care team for the patient with impaired swallowing and/or limited nutrition. • Teach the patient and family to recognize the symptoms of dysphagia. • Remain with the dysphagic patient during meals to prevent or assist with choking episodes.

What might you NOTICE if the patient has inadequate digestion and nutrition as a result of chronic esophageal problems?

• Dysphagia (difficulty swallowing) • Odynophagia (painful swallowing) • Dyspepsia (indigestion) • Regurgitation (reflux) • Eructation (belching) • Chronic cough • Choking • Halitosis (foul breath) • Weight loss • Vomiting • Chest pain

Key Points: Health Promotion and Maintenance

• Teach the patient oral exercises aimed at improving swallowing. • Stress the importance of recognizing and controlling reflux through nutrition therapy and medications to avoid further esophageal damage that could lead to Barrett's esophagus. • Teach the patient to elevate the head of the bed by 6 inches for sleep to prevent nighttime reflux. • Instruct the patient to sleep in the right side-lying position to minimize the effects of nighttime episodes of reflux. • Teach the patient with esophageal cancer to monitor his or her body weight and to notify the health care provider of weight loss. • Teach the patient to avoid alcoholic beverages, smoking, and other substances as listed in Chart 54-2 because they lead to increased gastroesophageal reflux. • Teach the patient to prevent gas bloat syndrome by avoiding drinking carbonated beverages, eating gas-producing foods, chewing gum, and drinking with a straw. • Review postprocedure instructions for patients having the Stretta procedure for GERD as outlined in Chart 54-3.