GERD: A Primer for Nurses


GERD: A Primer for Nurses Vol. 3 Issue 18 Page 15

GERD: A Primer for Nurses

By Sandra L. Holmes, MSN, CGRN, APRN, BC

The goal of this CE offering is to provide nurses with current in formation about gastroeso phageal reflux disease (GERD), with an emphasis on pharmacological man age ment that can be applied to practice. After you have completed reading this article, you will be able to:

• Discuss the pathophysiology of GERD.

• Compare and contrast the various medications that are used to treat GERD.

• Describe the lifestyle modifications in the management of GERD.

Gastroesophageal reflux disease (GERD) is a common disorder of the gastrointestinal system. It affects an estimated 25 -35 percent of the U.S. population.1 The National In stitute of Diabetes and Digestive and Kidney Diseases (NIDDK) re ports more than 60 million Americans experience GERD at least once a month, and approximately 25 million adults suffer from heartburn daily.2 Symptoms of the disease may vary, resolve or relapse at different periods, causing patients to delay seeking medical attention.

It is important that nurses be knowledgeable of all aspects of the disease – from pathophysiology to management – in order to in crease the patient’s knowledge and understanding of the disease, identify modifications needed to alleviate symptoms and reinforce treatments to reduce risk of complications of GERD.

PATHOPHYSIOLOGY

GERD affects the lower esophageal sphincter (LES), a muscle con necting the esophagus and stomach. Gastric contents back up, or reflux, into the esophagus due to changes in muscle tone or in creas ed pressure below the sphincter.1 Other factors contributing to the pathophysiology of GERD include decreased clearance of acid from the esophagus through peristalsis, secretion of bicarbonate, pepsin and bile salts, gastric distention, hiatal hernia, pregnancy and obesity.1,3,4

As a result of acid exposure, changes in the mucosal lining of the esophagus occur. These changes are associated with troublesome symptoms and the serious complications of GERD. The severity of symptoms and incidence of complications is related to the duration and type of acid exposure.1,3 Table 1 illustrates common manifestations of GERD.

DIAGNOSIS AND TREATMENT

Diagnosis of GERD is usually straightforward. Information ob tain ed via history and physical assessment often suffices, as long as cardiac or other refractory symptoms do not exist. When deemed necessary, barium swallow, endoscopy with mucosal biopsy, the Bernstein test or acid perfusion test (perfusion of normal saline and acidic solutions separately into the esophagus via a nasogastric tube to distinguish chest pains caused by esophagitis from those caused by cardiac disorders), esophageal manometry or 24-hour ambulatory pH monitoring may be scheduled.1,3,4,5

The goals of treatment for GERD are to relieve symptoms; heal damaged esophageal mucosa; prevent complications such as the esophageal ulcers that may be a source of bleeding or discomfort; strictures that make swallowing difficult, and Barrett’s esophagus – a progressive change in the mucosal lining of the esophagus associated with adenocarcinoma of the esophagus – and maintain remission.1,4 Implementation of nonpharmacological interventions and patient education are often enough to alleviate symptoms. Pa tients who continue to have persistent symptoms after a trial of life style modifications and over-the-counter (OTC) medications should be started on more aggressive treatments.1,3,4 Table 2 identifies common lifestyle modifications for treating GERD symptoms.4

PHARMACOLOGICAL MANAGEMENT OF GERD

When medications are required to treat the disease, patients must be aware of the indication, dosage, potential side effects and drug interactions. Pharmacological management of GERD includes use of OTC medications, prescription H2 blockers alone or in combination with proton pump inhibitors (PPIs), and use of prokinetic drugs1,3 (Table 3). Antacids, alginic acid preparations and OTC H2 blockers are the drugs used most often for symptom relief. Inhibition of acid production by proton pump inhibitors and increasing the clearance of acids with prokinetic agents are also effective in treating GERD.

Antacids neutralize acid refluxate in the esophagus. Alginic acid preparations form a foam barrier on top of the gastric contents that prevents acid reflux from occurring. For maximum relief of symptoms, antacid or alginic medications should be taken immediately after meals if symptoms occur. Patients should be aware of potential side effects such as constipation or diarrhea. Knowledge of al teration in systemic levels of calcium, magnesium, aluminum or bi carbonate is also important for patients with renal and cardiovascular disease. Potential interactions with other medications such as some antibiotics and iron preparations should be discussed so ap propriate dose and schedule adjustments can be made.

H2 BLOCKERS FOR OCCASIONAL SYMPTOMS

Over-the-counter H2 blockers are useful in treating occasional GERD symptoms. They should be taken before meals to prevent the occurrence of symptoms. These drugs are half the dosage strength of the prescription products. Although not as fast acting as antacids, they provide longer periods of symptom relief. Prescription doses of H2 blockers are the first-line pharmacological treatment for refractory symptoms, healing esophagitis and maintaining re mission. This class of drugs acts by inhibiting histamine stimulation of the gastric parietal cells, which causes suppression of gastric acid secretion.1,3 H2 blockers are help ful in pa tients who ex perience symptoms at night due to nocturnal acid se cretion, and are found to reduce both volume of gastric juices and its hydrogen ion concentration. The available H2 block ers differ in strength, but equivalent dos ages are equally effective.

H2 blockers are well tolerated by most pa tients. Adverse effects include headache and dizziness, along with constipation or dia r rhea. Drug interactions include decreased absorption of some antimicrobials and de layed meta bolism of some drugs in renal pa tients. Ad verse events are more common with cimeti dine (Tagamet®, SmithKline Beecham) than other agents in this class because of this drug’s abil ity to inhibit the metabolism of drugs through the cytochrome P450 isoenzyme systems.

EFFECT OF PPIs

PPIs inhibit gastric acid secretion by irreversibly inhibiting the H+-ATPase pump in gastric parietal cells.1,3 A greater degree and duration of gastric acid suppression is ob tained by blocking this pathway compared to other treatments. This class of drugs is fairly well tolerated. Common side effects in clude nausea, constipation, diarrhea, head ache and skin rash. The effects of PPIs on the metabolism and aborption of other drugs taken by the patients should be assessed and monitored. PPIs are more costly than standard H2 blockers or other agents; however, in pa tients with severe symptoms or refractory disease, the medication is more cost-effective because of its higher healing and remission rate.

PROKINETIC DRUGS PRESCRIBED LESS

Prokinetic drugs are favored in the treatment of GERD when a motility defect is identified.1,3 Increasing LES pressure and im proving esophageal peristalsis can be achieved in some patients using these drugs. How ever, prokinetic drugs are no longer frequently prescribed due to increasing adverse side effects and interactions. Potential central ner vous system effects such as sedation, fati gue, dystonia and headache, dry mouth, constipation, nausea and diarrhea were associated with use of prokinetic drugs. An increase in the risk for bradycardia, hypotension and other fatal cardiac problems also was found in some patients who used these drugs.

Compliance with lifestyle modifications and adherence to therapy are required to meet treatment goals. Following an unsuccessful 8-12 week trial period of medications and modifications, or the development of complications, further testing or surgical intervention may be required.1,3 Anti-reflux surgery is typically reserved for patients re quir ing lifetime medical therapy due to refractory reflux disease or intolerable symptoms, recurrent strictures or aspiration, and bleeding from nonhealing ulcers.

EDUCATING PATIENTs

It is important that the nurse involved in the care of the patient with GERD educate the patient on all aspects of treatment and management. An educated patient is an em powered patient. Knowledge of simple life style modifications and medication therapy may be the only measures needed to reach treatment goals. This information promotes increased adherence with therapy and prevents adverse events.

A nurse with knowledge of the pathophy siology and management of GERD is able to assist the patient in identifying and implementing therapeutic interventions to alleviate symptoms, heal damaged tissue, prevent complications and maintain remission of the disease. n

References

1. Scott, M., Gelhot, A.R. (1999). Gastroesophageal reflux disease: Diagnosis and management. American Family Physi cian. Retrieved March 12, 2001 from the World Wide Web: http://www.aafp.org/afp/990301ap/1161.html

2. National Digestive Disease Information Clearing house. (2000). Gastroesophageal reflux disease (hiatal hernia and heartburn). Retrieved March 12, 2001 from the World Wide Web: http://www.niddk.nih.gov/health/digest/ pubs/heartbrn/heartbrn.htm

3. Covington, C. (2001). Soothing the burn: Modern management of GERD. ADVANCE for Nurse Practitioners, 9(7), 65-72.

4. Holmes, S. (2000). Gastroesophageal reflux disease: Primary care management issues. Advance for Nurse Practi tioners, 8(3), 75-76.

Sandra Holmes is currently a PhD student in the nursing doctoral program at the University of Tennessee Health Science Center in Memphis.

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