Part 2 Management of Patients With Oral and Esophageal Disorders - PowerPoint PPT Presentation


Title: Part 2 Management of Patients With Oral and Esophageal Disorders


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Part 2Management of PatientsWith Oral
andEsophageal Disorders
  • 2ed Years Student, 2ed Semester
  • Miss Iman shaweesh
  • January 2008

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Disorders of the TeethDENTAL PLAQUE AND CARIES
  • Tooth decay is an erosive process that begins
    with the action of bacteria on fermentable
    carbohydrates in the mouth, which produces acids
    that dissolve tooth enamel. The extent of damage
    to the teeth depends on the following

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  • The presence of dental plaque
  • The strength of the acids and the ability of the
    saliva to neutralize them
  • The length of time the acids are in contact with
    the teeth
  • The susceptibility of the teeth to decay

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Prevention
  • Measures used to prevent and control dental
    caries include practicing effective mouth care,
    reducing the intake of starches and
  • sugars (refined carbohydrates), applying fluoride
    to the teeth or
  • drinking fluoridated water, refraining from
    smoking, controlling diabetes, and using pit and
    fissure sealants

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Disorders of the Lips, Mouth, and Gums
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Abnormalities of the Mouth
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Abnormalities of the Gums
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Gerontologic Considerations
  • Many medications taken by the elderly cause dry
    mouth, which is uncomfortable, impairs
    communication, and increases the risk of oral
    infection. These medications include the
    following
  • Diuretics
  • Antihypertensive medications
  • Anti-inflammatory agents
  • Antidepressant medications

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Gerontologic Considerations
  • Poor dentition can exacerbate problems of aging,
    such as
  • Decreased food intake
  • Loss of appetite
  • Social isolation
  • Increased susceptibility to systemic
    infection
  • (from periodontal disease)
  • Trauma to the oral cavity secondary to
    thinner,
  • less vascular oral mucous membranes

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DENTOALVEOLAR ABSCESSOR PERIAPICAL ABSCESS
  • more commonly referred to as an abscessed,
    involves the collection of pus in the apical
    dental periosteum (fibrous membrane supporting
    the tooth structure) and the tissue surrounding
    the apex of the tooth (where it is suspended in
    the jaw bone). The abscess has two forms acute
    and chronic. Acute periapical abscess is usually
    secondary to a suppurative pulpitis (a
    pus-producing inflammation of the dental pulp)

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Clinical Manifestations
  • The abscess produces a dull, gnawing, continuous
    pain, often with a surrounding cellulitis and
    edema of the adjacent facial structures, and
    mobility of the involved tooth. The gum opposite
    the apex of the tooth is usually swollen on the
    cheek side. Swelling and cellulitis of the facial
    structures may make it difficult for the patient
    to open the mouth.

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Management
  • In the early stages of an infection, a dentist or
    dental surgeon
  • may perform a needle aspiration or drill an
    opening into the pulp chamber to relieve tension
    and pain and to provide drainage.
  • After the inflammatory reaction has subsided, the
    tooth may be extracted or root canal therapy
    performed. Antibiotics may be prescribed.

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Nursing Management
  • The nurse assesses the patient for bleeding after
    treatment and instructs the patient to use a warm
    saline or warm water mouth rinse to keep the area
    clean.
  • The patient is also instructed to take
    antibiotics
  • and analgesics as prescribed,
  • to advance from a liquid diet
  • to a soft diet as tolerated, and to keep
    follow-up appointments.

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Disorders of the Jaw
  • Temporomandibular disorders are categorized as
    follows (National Oral Health Information)
  • Myofascial paina discomfort in the muscles
    controlling jaw function and in neck and shoulder
    muscles
  • Internal derangement of the jointa dislocated
    jaw, a displaced disc, or an injured condyle
  • Degenerative joint diseaserheumatoid arthritis
    or osteoarthritis in the jaw joint

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Disorders of the Salivary Glands
  • Parotitis (inflammation of the parotid gland) is
    the most common inflammatory condition of the
    salivary glands, although inflammation can occur
    in the other salivary glands as well. Mumps
    (epidemic parotitis), a communicable disease
    caused by viral infection and most commonly
    affecting children, is an inflammation of a
    salivary gland, usually the parotid.

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SIALADENITIS
  • (inflammation of the salivary glands) may be
    caused by dehydration, radiation therapy, stress,
    malnutrition, salivary gland calculi (stones), or
    improper oral hygiene. The inflammation is
    associated with infection by S. aureus,
    Streptococcus viridans, or pneumococcus.

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SALIVARY CALCULUS (SIALOLITHIASIS)
  • Sialolithiasis, or salivary calculi (stones),
    usually occurs in the submandibular gland.
    Salivary gland ultrasonography or sialography
    (x-ray studies filmed after the injection of a
    radiopaque substance into the duct) may be
    required to demonstrate obstruction of the duct
    by stenosis. Salivary calculi are formed mainly
    from calcium
  • phosphate.

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Cancer of the Oral Cavity
  • Cancers of the oral cavity, which can occur in
    any part of the mouth or throat, are curable if
    discovered early. These cancers are associated
    with the use of alcohol and tobacco.
  • Cancer of the oral cavity accounts for less than
    2 of all cancer deaths in the United States. Men
    are afflicted more often than women.

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Pathophysiology
  • Malignancies of the oral cavity are usually
    squamous cell cancers. Any area of the oropharynx
    can be a site for malignant growths, but the
    lips, the lateral aspects of the tongue, and the
    floor of the mouth are most commonly affected.

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Clinical Manifestations
  • Many oral cancers produce few or no symptoms in
    the early stages. Later, the most frequent
    symptom is a painless sore or mass that will not
    heal. A typical lesion in oral cancer is a
    painless
  • indurated (hardened) ulcer with raised edges.
    Tissue from any ulcer of the oral cavity that
    does not heal in 2 weeks should be examined
  • through biopsy.

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Medical Management
  • Surgical resection, radiation therapy,
    chemotherapy, or a combination of these therapies
    may be effective. In cancer of the lip, small
    lesions are usually excised liberally larger
    lesions involving more than one third of the lip
    may be more appropriately treated by radiation
    therapy because of superior cosmetic results.

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  • If the cancer has spread to the lymph nodes, the
    surgeon may perform a neck dissection. Surgical
    treatments leave a less functional tongue
    surgical procedures include hemiglossectomy
    (surgical removal of half of the tongue) and
    total glossectomy (removal of the tongue).
  • Often cancer of the oral cavity has metastasized
    through the extensive lymphatic channel in the
    neck region

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Neck Dissection
  • Malignancies of the head and neck include those
    of the oral cavity, oropharynx, hypopharynx,
    nasopharynx, nasal cavity,paranasal sinus, and
    larynx (Fig)
  • These cancers account for fewer than 5 of all
    cancers. Depending on the location and stage,
    treatment may consist of radiation therapy,
    chemotherapy, surg or a combination of these
    modalities.

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  • A radical neck dissection involves removal of all
    cervical lymph nodes from the mandible to the
    clavicle and removal of the sternocleidomastoid
    muscle, internal jugular vein, and spinal
    accessory muscle on one side of the neck.

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Group Discussion
  • Nursing Management
  • NURSING PROCESS THE PATIENT WITH CONDITIONS OF
    THE ORAL CAVITY
  • Neck Dissection
  • NURSING PROCESS THE PATIENT UNDERGOING A NECK
    DISSECTION

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Disorders of the Esophagus
  • The esophagus is a mucus-lined, muscular tube
    that carries food from the mouth to the stomach.
    It begins at the base of the pharynx and ends
    about 4 cm below the diaphragm. Its ability to
    transport food and fluid is facilitated by two
    sphincters. The upper esophageal sphincter, also
    called the hypopharyngeal sphincter, is located
    at thejunction of the pharynx and the esophagus.
    The lower esophageal sphincter, also called the
    gastroesophageal sphincter, is located at the
    junction of the esophagus and the stomach.

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Dysphagia
  • (difficulty swallowing) is the most common
    symptom of esophageal disease. This symptom may
    vary from an uncomfortable
  • feeling that a bolus of food is caught in the
    upper esophagus (before it eventually passes into
    the stomach) to acute pain
  • on swallowing (odynophagia).

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Achalasia
  • is absent or ineffective peristalsis of the
    distal esophagus accompanied by failure of the
    esophageal sphincter to relax in response to
    swallowing. Narrowing of the esophagus just above
    the stomach results in a gradually increasing
    dilation of the esophagus in the upper chest.
    Achalasia may progress slowly and occurs most
    often in people 40 years of age or older.

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Clinical Manifestations
  • The primary symptom of achalasia is difficulty in
    swallowing both liquids and solids. The patient
    has a sensation of food sticking in the lower
    portion of the esophagus. As the condition
    progresses, food is commonly regurgitated, either
    spontaneously or intentionally by the patient to
    relieve the discomfort produced by prolonged
    distention of the esophagus by food that will not
    pass into the stomach. The patient may also
    complain of chest pain and heartburn
  • (pyrosis).

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Assessment and Diagnostic Findings
  • X-ray studies show esophageal dilation above the
    narrowing at the gastroesophageal junction.
    Barium swallow, computed tomography
  • (CT) of the esophagus, and endoscopy may be used
    for diagnosis however, the diagnosis is
    confirmed by manometry, a process in which the
    esophageal pressure is measured by a radiologist
    or gastroenterologist.

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Management
  • The patient should be instructed to eat slowly
    and to drink fluids with meals. As a temporary
    measure, calcium channel blockers and nitrates
    have been used to decrease esophageal pressure
    and improve swallowing.
  • Achalasia may be treated conservatively by
    pneumatic dilation to stretch the narrowed area
    of the esophagus (Fig. 35-6). Pneumatic dilation
    has a high success rate.

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Achalasia may be treated surgically by
esophagomyotomy
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DIFFUSE SPASM
  • spasm is a motor disorder of the esophagus. The
    cause is unknown, but stressful situations can
    produce contractions of the esophagus. It is more
    common in women and usually manifests in middle
    age.
  • characterized by difficulty or pain on
    swallowing (dysphagia, odynophagia) and by chest
    pain similar to that of coronary artery spasm.

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Assessment and Diagnostic Findings
  • Esophageal manometry, which measures the motility
    of the esophagus and the pressure within the
    esophagus, indicate that simultaneous
    contractions of the esophagus occur irregularly.
    Diagnostic x-ray studies after ingestion of
    barium show separate areas of spasm.

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Management
  • Conservative therapy includes administration of
    sedatives and long-acting nitrates to relieve
    pain. Calcium channel blockers have also been
    used to manage diffuse spasm. Small, frequent
  • feedings and a soft diet are usually
    recommended to decrease the esophageal pressure
    and irritation that lead to spasm.

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HIATAL HERNIA
  • The esophagus enters the abdomen through an
    opening in the diaphragm and empties at its lower
    end into the upper part of the stomach. Normally,
    the opening in the diaphragm encircles the
    esophagus tightly, and the stomach lies
    completely within the abdomen. In a condition
    known as hiatus (or hiatal) hernia, the opening
    in the diaphragm through which the esophagus
    passes becomes enlarged, and part of the upper
    stomach tends to move up into the lower portion
    of the thorax.

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There are two types of hiatal hernias sliding
and paraesophageal
  • Sliding, or type I, hiatal hernia occurs when the
    upper stomach and the gastroesophageal junction
    (GEJ) are displaced upward and slide in and out
    of the thorax (Fig. 35-8A). About 90 of patients
    with esophageal hiatal hernia have a sliding
    hernia.
  • A paraesophageal hernia occurs when all or part
    of the stomach pushes through the diaphragm
    beside the esophagus

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Clinical Manifestations
  • may have heartburn, regurgitation, and dysphagia,
    but at least 50 of patients are asymptomatic.
    Sliding hiatal hernia is often implicated in
    reflux. The patient with a paraesophageal hernia
    usually feels a sense of fullness after eating or
    may be asymptomatic.

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Assessment and Diagnostic Findings
  • Diagnosis is confirmed by
  • x-ray studies,
  • barium swallow,
  • and fluoroscopy.

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Management
  • Management for an axial hernia includes frequent,
    small feedings that can pass easily through the
    esophagus. The patient is advisednot to recline
    for 1 hour after eating, to prevent reflux or
    movement of the hernia, and to elevate the head
    of the bed on 4- to 8-inch (10- to 20-cm) blocks
    to prevent the hernia from sliding upward.
    Surgery is indicated in about 15 of patients.

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Management
  • Medical and surgical management of a
    paraesophageal hernia is similar to that for
    gastroesophageal reflux however, paraesophageal
    hernias may require emergency surgery to correct
    torsion (twisting) of the stomach or other body
    organ that leads to restriction of blood flow to
    that area.

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DIVERTICULUM
  • A diverticulum is an outpouching of mucosa and
    submucosa that protrudes through a weak portion
    of the musculature. Diverticula may occur in one
    of the three areas of the esophagusthe
    pharyngoesophageal or upper area of the
    esophagus, the midesophageal area, or the
    epiphrenic or lower area of the esophagus or
    they may occur along the border of the esophagus
    intramurally.

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  • The most common type of diverticulum, which is
    found three times more frequently in men than in
    women, is Zenkers diverticulum (also known as
    pharyngoesophageal pulsion diverticulum or a
    pharyngeal pouch). It occurs posteriorly through
    the cricopharyngeal muscle in the midline of the
    neck. It is usually seen in people older than 60
    years of age.

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Clinical Manifestations
  • include difficulty swallowing, fullness in the
  • neck, belching, regurgitation of undigested
    food, and gurglingnoises after eating.
  • The diverticulum, or pouch, becomes filled with
    food or liquid. When the patient assumes a
    recumbent position, undigested food is
    regurgitated, and coughing may be caused by
    irritation of the trachea.
  • Halitosis and a sour taste in the mouth are also
    common because of the decomposition of food
    retained in the diverticulum.

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Assessment and Diagnostic Findings
  • A barium swallow may be performed to determine
    the exact nature and location of a diverticulum.
  • Manometric studies are often performed for
    patients with epiphrenic diverticula to rule out
    a motor disorder.
  • Esophagoscopy usually is contraindicated because
    of the danger of perforation of the diverticulum,

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Management
  • Because pharyngoesophageal pulsion diverticulum
    is progressive,the only means of cure is surgical
    removal of the diverticulum. During surgery, care
    is taken to avoid trauma to the common carotid
    artery and internal jugular veins.
  • Food and fluids are withheld until x-ray studies
  • show no leakage at the surgical site. The
    diet begins with liquids and progresses as
    tolerated.

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PERFORATION
  • The esophagus is not an uncommon site of injury.
    Perforation may result from stab or bullet wounds
    of the neck or chest, trauma from motor vehicle
    crash, caustic injury from a chemical burn
    (described later), or inadvertent puncture by a
    surgical instrument during examination or
    dilation.

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Clinical Manifestations
  • The patient has persistent pain followed by
    dysphagia. Infection,
  • fever, leukocytosis, and severe hypotension may
    be noted. In
  • some instances, signs of pneumothorax are
    observed.

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Assessment and Diagnostic Findings
  • Diagnostic x-ray studies and fluoroscopy are used
    to identify the site of the injury.

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Management
  • Because of the high risk of infection,
    broad-spectrum antibiotic therapy is initiated.
    A nasogastric tube is inserted to provide suction
    and to reduce the amount of gastric juice that
    can reflux into the esophagus and mediastinum.
    Nothing is given by mouth nutritional needs are
    met by parenteral nutrition. Parenteral nutrition
    is preferred to gastrostomy because the latter
    might cause reflux into the esophagus. Surgery
    may be necessary to close the wound, and
    postoperative nutritional support then becomes a
    primary concern.

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CHEMICAL BURNS
  • Chemical burns of the esophagus may be caused by
    undissolved medications in the esophagus. This
    occurs more frequently in the elderly than it
    does among the general adult population. A
    chemical burn may also occur after swallowing of
    a battery, which may release caustic alkaline.
    Chemical burns of the esophagus occur most often
    when a patient, either intentionally or
    unintentionally, swallows a strong acid or base

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RX
  • Esophagoscopy and barium swallow- to determine
    the extent and severity of damage.
  • The patient is NPO, and IV fluids adm
  • A NGT may be inserted by the physician.
  • Vomiting and gastric lavage are avoided to
    prevent further exposure of the esophagus to the
    caustic agent.

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RX
  • The use of corticosteroids to reduce inflammation
    and minimize subsequent scarring and stricture
    formation is of questionable value.
  • The value of the prophylactic use of antibiotics
    for these patients has also been questioned
  • For strictures that do not respond to dilation,
    surgical management is necessary.

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GASTROESOPHAGEAL REFLUX DISEASE
  • Some degree of gastroesophageal reflux (back-flow
    of gastric or duodenal contents into the
    esophagus) is normal in both adults and children.
    Excessive reflux may occur because of an
    incompetent lower esophageal sphincter, pyloric
    stenosis, or a motility disorder. The incidence
    of reflux seems to increase with aging.

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Clinical Manifestations(GERD)
  • pyrosis (burning sensation in the esophagus),
  • dyspepsia (indigestion), regurgitation,
  • dysphagia or odynophagia (difficulty swallowing,
  • pain on swallowing), hypersalivation, and
    esophagitis. The symptoms may mimic those of a
    heart attack.

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Assessment and Diagnostic Findings(GERD)
  • Diagnostic testing may include an endoscopy or
    barium swallow to evaluate damage to the
    esophageal mucosa.
  • Ambulatory 12- to 36-hour esophageal pH
    monitoring is used to evaluate the degree
  • of acid reflux.
  • Bilirubin monitoring (Bilitec) is used to measure
  • bile reflux patterns.

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Management (GERD)
  • Management begins with teaching the patient to
    avoid situations that decrease lower esophageal
    sphincter pressure or cause esophageal
    irritation.
  • The patient is instructed to eat a low-fat diet
  • to avoid caffeine, tobacco, beer, milk, foods
    containing peppermint or spearmint, and
    carbonated beverages to avoid eating or drinking

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Management (GERD)
  • 2 hours before bedtime to maintain normal body
    weight to avoid tight-fitting clothes to
    elevate the head of the bed on 6- to 8-inch (15-
    to 20-cm) blocks and to elevate the upper body
    on pillows.
  • If reflux persists, the patient may be given
    medications such as antacids or histamine
    receptor blockers. Proton pump inhibitors
    (medications that decrease the release of gastric
    acid,

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Management (GERD)
  • Surgical management involves a fundoplication
    (wrapping of a portion of the gastric fundus
    around the sphincter area of the esophagus).
    Fundoplication may be performed by laparoscopy.

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CANCER OF THE ESOPHAGUS
  • USA carcinoma of the esophagus occurs more than
    three times as often in men as in women. It is
    seen more frequently in African Americans than in
    Caucasians and usually occurs in the fifth decade
    of life. Cancer of the esophagus has a much
    higher incidence in other parts of the world,
    including China and northern Iran

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  • cancer of the esophagus has been associated with
    ingestion of alcohol and with the use of tobacco.
    There seems to be an association between GERD and
    adenocarcinoma of the esophagus. People with
    Barretts esophagus (which is caused by chronic
    irritation of mucous membranes due to reflux of
    gastric and duodenal contents) have a higher
    incidence

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Pathophysiology
  • Esophageal cancer is usually of the squamous cell
    epidermoid type however, the incidence of
    adenocarcinoma of the esophagus is increasing in
    the United States.
  • Tumor cells may spread beneath the esophageal
    mucosa or directly into, through, and beyond the
    muscle layers into the lymphatics.

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Clinical Manifestations
  • Symptoms include dysphagia, initially with solid
    foods and eventually with liquids a sensation of
    a mass in the throat painful swallowing
    substernal pain or fullness and, later,
    regurgitation of undigested food with foul breath
    and hiccups.

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  • As the tumor progresses and the obstruction
    becomes more complete, even liquids cannot pass
    into the stomach. Regurgitation of food and
    saliva occurs, hemorrhage may take place, and
    progressive loss of weight
  • Later symptoms include substernal pain,
    persistent hiccup, respiratory difficulty, and
    foul breath. The delay between the onset of early
    symptoms and the time when the patient seeks
    medical advice is often 12 to 18 months.

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Assessment and Diagnostic Findings
  • new endoscopic techniques are being studied for
    screening and diagnosis of esophageal cancer,
    currently diagnosis is confirmed most often by
    EGD with biopsy and brushings.
  • Endoscopic ultrasound or mediastinoscopy
  • is used to determine whether the cancer has
    spread to the nodes and other mediastinal
    structures.

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Medical Management
  • If esophageal cancer is found at an early stage,
    treatment goals may be directed toward cure
    however, it is often found in late stages, making
    relief of symptoms the only reasonable goal of
    therapy.
  • Treatment may include surgery, radiation,
    chemotherapy, or a combination of these
    modalities,

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  • Standard surgical management includes a total
    resection of the esophagus (esophagectomy) with
    removal of the tumor plus a wide tumor-free
    margin of the esophagus and the lymph nodes in
    the area.
  • When tumors occur in the cervical or upper
    thoracic area, esophageal continuity may be
    maintained by free jejunal graft transfer, in
    which the tumor is removed and the area is
    replaced with a portion of the jejunum (Fig).

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  • A segment of the colon may be used, or the
  • stomach can be elevated into the chest and the
    proximal section of the esophagus anastomosed to
    the stomach.
  • Tumors of the lower thoracic esophagus are more
    amenable to surgery than are tumors located
    higher in the esophagus, and gastrointestinal
    tract integrity is maintained by anastomosing the
    lower esophagus to the stomach.

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  • Surgical resection of the esophagus has a
    relatively high mortality rate because of
    infection, pulmonary complications, or leakage
    through the anastomosis.
  • Postoperatively, the patient will have a
    nasogastric tube in place that should not be
    manipulated. The patient is given nothing by
    mouth until x-ray studies confirm that
  • the anastomosis is secure and not leaking.

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Nursing Management
  • Intervention is directed toward improving the
    patients nutritional and physical condition in
    preparation for surgery, radiation therapy, or
    chemotherapy.
  • A program to promote weigh gain based on a
    high-calorie and high-protein diet, in liquid or
    soft form, is provided if adequate food can be
    taken by mouth.

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Nursing Management
  • informed about the nature of the postoperative
    equipment that will be used, including that
    required for closed chest drainage, nasogastric
    suction, parenteral fluid therapy, and gastric
    intubation.
  • After recovering from the effects of anesthesia,
    the patient is placed in a low Fowlers position,
    and later in a Fowlers position, to assist in
    preventing re- flux of gastric secretions.

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Nursing Management
  • The patient is observed carefully
    for-regurgitation and dyspnea. A common
    postoperative complication is aspiration
    pneumonia.
  • If jejunal grafting has been performed, the nurse
    checks for graft viability hourly for at least
    the first 12 hours. To make the graft visible,

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Nursing Management
  • Moist gauze covers the external portion of the
    graft. The gauze is removed briefly to assess the
    graft for color and to assess for the presence of
    a pulse by means of Doppler ultrasonography.
  • The nasogastric tube is removed 5 to 7 days after
    surgery, and a barium swallow is performed to
    assess for any anastomotic leak before the
    patient is allowed to eat.

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Nursing Management
  • Once feeding begins, the nurse encourages the
    patient to swallow small sips of water and,
    later, small amounts of pureed food.
  • After each meal, the patient remains upright for
    at least 2 hours to allow the food to move
    through the gastrointestinal tract.
  • If radiation is part of the therapy, the
    patients appetite is further depressed and
    esophagitis may occur.

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Part 2 Management of Patients With Oral and Esophageal Disorders

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Title: Part 2 Management of Patients With Oral and Esophageal Disorders


1
Part 2Management of PatientsWith Oral
andEsophageal Disorders
  • 2ed Years Student, 2ed Semester
  • Miss Iman shaweesh
  • January 2008

2
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3
Disorders of the TeethDENTAL PLAQUE AND CARIES
  • Tooth decay is an erosive process that begins
    with the action of bacteria on fermentable
    carbohydrates in the mouth, which produces acids
    that dissolve tooth enamel. The extent of damage
    to the teeth depends on the following

4
  • The presence of dental plaque
  • The strength of the acids and the ability of the
    saliva to neutralize them
  • The length of time the acids are in contact with
    the teeth
  • The susceptibility of the teeth to decay

5
Prevention
  • Measures used to prevent and control dental
    caries include practicing effective mouth care,
    reducing the intake of starches and
  • sugars (refined carbohydrates), applying fluoride
    to the teeth or
  • drinking fluoridated water, refraining from
    smoking, controlling diabetes, and using pit and
    fissure sealants

6
Disorders of the Lips, Mouth, and Gums
7
Abnormalities of the Mouth
8
Abnormalities of the Gums
9
Gerontologic Considerations
  • Many medications taken by the elderly cause dry
    mouth, which is uncomfortable, impairs
    communication, and increases the risk of oral
    infection. These medications include the
    following
  • Diuretics
  • Antihypertensive medications
  • Anti-inflammatory agents
  • Antidepressant medications

10
Gerontologic Considerations
  • Poor dentition can exacerbate problems of aging,
    such as
  • Decreased food intake
  • Loss of appetite
  • Social isolation
  • Increased susceptibility to systemic
    infection
  • (from periodontal disease)
  • Trauma to the oral cavity secondary to
    thinner,
  • less vascular oral mucous membranes

11
DENTOALVEOLAR ABSCESSOR PERIAPICAL ABSCESS
  • more commonly referred to as an abscessed,
    involves the collection of pus in the apical
    dental periosteum (fibrous membrane supporting
    the tooth structure) and the tissue surrounding
    the apex of the tooth (where it is suspended in
    the jaw bone). The abscess has two forms acute
    and chronic. Acute periapical abscess is usually
    secondary to a suppurative pulpitis (a
    pus-producing inflammation of the dental pulp)

12
Clinical Manifestations
  • The abscess produces a dull, gnawing, continuous
    pain, often with a surrounding cellulitis and
    edema of the adjacent facial structures, and
    mobility of the involved tooth. The gum opposite
    the apex of the tooth is usually swollen on the
    cheek side. Swelling and cellulitis of the facial
    structures may make it difficult for the patient
    to open the mouth.

13
Management
  • In the early stages of an infection, a dentist or
    dental surgeon
  • may perform a needle aspiration or drill an
    opening into the pulp chamber to relieve tension
    and pain and to provide drainage.
  • After the inflammatory reaction has subsided, the
    tooth may be extracted or root canal therapy
    performed. Antibiotics may be prescribed.

14
Nursing Management
  • The nurse assesses the patient for bleeding after
    treatment and instructs the patient to use a warm
    saline or warm water mouth rinse to keep the area
    clean.
  • The patient is also instructed to take
    antibiotics
  • and analgesics as prescribed,
  • to advance from a liquid diet
  • to a soft diet as tolerated, and to keep
    follow-up appointments.

15
Disorders of the Jaw
  • Temporomandibular disorders are categorized as
    follows (National Oral Health Information)
  • Myofascial paina discomfort in the muscles
    controlling jaw function and in neck and shoulder
    muscles
  • Internal derangement of the jointa dislocated
    jaw, a displaced disc, or an injured condyle
  • Degenerative joint diseaserheumatoid arthritis
    or osteoarthritis in the jaw joint

16
Disorders of the Salivary Glands
  • Parotitis (inflammation of the parotid gland) is
    the most common inflammatory condition of the
    salivary glands, although inflammation can occur
    in the other salivary glands as well. Mumps
    (epidemic parotitis), a communicable disease
    caused by viral infection and most commonly
    affecting children, is an inflammation of a
    salivary gland, usually the parotid.

17
SIALADENITIS
  • (inflammation of the salivary glands) may be
    caused by dehydration, radiation therapy, stress,
    malnutrition, salivary gland calculi (stones), or
    improper oral hygiene. The inflammation is
    associated with infection by S. aureus,
    Streptococcus viridans, or pneumococcus.

18
SALIVARY CALCULUS (SIALOLITHIASIS)
  • Sialolithiasis, or salivary calculi (stones),
    usually occurs in the submandibular gland.
    Salivary gland ultrasonography or sialography
    (x-ray studies filmed after the injection of a
    radiopaque substance into the duct) may be
    required to demonstrate obstruction of the duct
    by stenosis. Salivary calculi are formed mainly
    from calcium
  • phosphate.

19
Cancer of the Oral Cavity
  • Cancers of the oral cavity, which can occur in
    any part of the mouth or throat, are curable if
    discovered early. These cancers are associated
    with the use of alcohol and tobacco.
  • Cancer of the oral cavity accounts for less than
    2 of all cancer deaths in the United States. Men
    are afflicted more often than women.

20
Pathophysiology
  • Malignancies of the oral cavity are usually
    squamous cell cancers. Any area of the oropharynx
    can be a site for malignant growths, but the
    lips, the lateral aspects of the tongue, and the
    floor of the mouth are most commonly affected.

21
Clinical Manifestations
  • Many oral cancers produce few or no symptoms in
    the early stages. Later, the most frequent
    symptom is a painless sore or mass that will not
    heal. A typical lesion in oral cancer is a
    painless
  • indurated (hardened) ulcer with raised edges.
    Tissue from any ulcer of the oral cavity that
    does not heal in 2 weeks should be examined
  • through biopsy.

22
Medical Management
  • Surgical resection, radiation therapy,
    chemotherapy, or a combination of these therapies
    may be effective. In cancer of the lip, small
    lesions are usually excised liberally larger
    lesions involving more than one third of the lip
    may be more appropriately treated by radiation
    therapy because of superior cosmetic results.

23
  • If the cancer has spread to the lymph nodes, the
    surgeon may perform a neck dissection. Surgical
    treatments leave a less functional tongue
    surgical procedures include hemiglossectomy
    (surgical removal of half of the tongue) and
    total glossectomy (removal of the tongue).
  • Often cancer of the oral cavity has metastasized
    through the extensive lymphatic channel in the
    neck region

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Neck Dissection
  • Malignancies of the head and neck include those
    of the oral cavity, oropharynx, hypopharynx,
    nasopharynx, nasal cavity,paranasal sinus, and
    larynx (Fig)
  • These cancers account for fewer than 5 of all
    cancers. Depending on the location and stage,
    treatment may consist of radiation therapy,
    chemotherapy, surg or a combination of these
    modalities.

26
  • A radical neck dissection involves removal of all
    cervical lymph nodes from the mandible to the
    clavicle and removal of the sternocleidomastoid
    muscle, internal jugular vein, and spinal
    accessory muscle on one side of the neck.

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Group Discussion
  • Nursing Management
  • NURSING PROCESS THE PATIENT WITH CONDITIONS OF
    THE ORAL CAVITY
  • Neck Dissection
  • NURSING PROCESS THE PATIENT UNDERGOING A NECK
    DISSECTION

29
Disorders of the Esophagus
  • The esophagus is a mucus-lined, muscular tube
    that carries food from the mouth to the stomach.
    It begins at the base of the pharynx and ends
    about 4 cm below the diaphragm. Its ability to
    transport food and fluid is facilitated by two
    sphincters. The upper esophageal sphincter, also
    called the hypopharyngeal sphincter, is located
    at thejunction of the pharynx and the esophagus.
    The lower esophageal sphincter, also called the
    gastroesophageal sphincter, is located at the
    junction of the esophagus and the stomach.

30
Dysphagia
  • (difficulty swallowing) is the most common
    symptom of esophageal disease. This symptom may
    vary from an uncomfortable
  • feeling that a bolus of food is caught in the
    upper esophagus (before it eventually passes into
    the stomach) to acute pain
  • on swallowing (odynophagia).

31
Achalasia
  • is absent or ineffective peristalsis of the
    distal esophagus accompanied by failure of the
    esophageal sphincter to relax in response to
    swallowing. Narrowing of the esophagus just above
    the stomach results in a gradually increasing
    dilation of the esophagus in the upper chest.
    Achalasia may progress slowly and occurs most
    often in people 40 years of age or older.

32
Clinical Manifestations
  • The primary symptom of achalasia is difficulty in
    swallowing both liquids and solids. The patient
    has a sensation of food sticking in the lower
    portion of the esophagus. As the condition
    progresses, food is commonly regurgitated, either
    spontaneously or intentionally by the patient to
    relieve the discomfort produced by prolonged
    distention of the esophagus by food that will not
    pass into the stomach. The patient may also
    complain of chest pain and heartburn
  • (pyrosis).

33
Assessment and Diagnostic Findings
  • X-ray studies show esophageal dilation above the
    narrowing at the gastroesophageal junction.
    Barium swallow, computed tomography
  • (CT) of the esophagus, and endoscopy may be used
    for diagnosis however, the diagnosis is
    confirmed by manometry, a process in which the
    esophageal pressure is measured by a radiologist
    or gastroenterologist.

34
Management
  • The patient should be instructed to eat slowly
    and to drink fluids with meals. As a temporary
    measure, calcium channel blockers and nitrates
    have been used to decrease esophageal pressure
    and improve swallowing.
  • Achalasia may be treated conservatively by
    pneumatic dilation to stretch the narrowed area
    of the esophagus (Fig. 35-6). Pneumatic dilation
    has a high success rate.

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Achalasia may be treated surgically by
esophagomyotomy
37
DIFFUSE SPASM
  • spasm is a motor disorder of the esophagus. The
    cause is unknown, but stressful situations can
    produce contractions of the esophagus. It is more
    common in women and usually manifests in middle
    age.
  • characterized by difficulty or pain on
    swallowing (dysphagia, odynophagia) and by chest
    pain similar to that of coronary artery spasm.

38
Assessment and Diagnostic Findings
  • Esophageal manometry, which measures the motility
    of the esophagus and the pressure within the
    esophagus, indicate that simultaneous
    contractions of the esophagus occur irregularly.
    Diagnostic x-ray studies after ingestion of
    barium show separate areas of spasm.

39
Management
  • Conservative therapy includes administration of
    sedatives and long-acting nitrates to relieve
    pain. Calcium channel blockers have also been
    used to manage diffuse spasm. Small, frequent
  • feedings and a soft diet are usually
    recommended to decrease the esophageal pressure
    and irritation that lead to spasm.

40
HIATAL HERNIA
  • The esophagus enters the abdomen through an
    opening in the diaphragm and empties at its lower
    end into the upper part of the stomach. Normally,
    the opening in the diaphragm encircles the
    esophagus tightly, and the stomach lies
    completely within the abdomen. In a condition
    known as hiatus (or hiatal) hernia, the opening
    in the diaphragm through which the esophagus
    passes becomes enlarged, and part of the upper
    stomach tends to move up into the lower portion
    of the thorax.

41
There are two types of hiatal hernias sliding
and paraesophageal
  • Sliding, or type I, hiatal hernia occurs when the
    upper stomach and the gastroesophageal junction
    (GEJ) are displaced upward and slide in and out
    of the thorax (Fig. 35-8A). About 90 of patients
    with esophageal hiatal hernia have a sliding
    hernia.
  • A paraesophageal hernia occurs when all or part
    of the stomach pushes through the diaphragm
    beside the esophagus

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Clinical Manifestations
  • may have heartburn, regurgitation, and dysphagia,
    but at least 50 of patients are asymptomatic.
    Sliding hiatal hernia is often implicated in
    reflux. The patient with a paraesophageal hernia
    usually feels a sense of fullness after eating or
    may be asymptomatic.

44
Assessment and Diagnostic Findings
  • Diagnosis is confirmed by
  • x-ray studies,
  • barium swallow,
  • and fluoroscopy.

45
Management
  • Management for an axial hernia includes frequent,
    small feedings that can pass easily through the
    esophagus. The patient is advisednot to recline
    for 1 hour after eating, to prevent reflux or
    movement of the hernia, and to elevate the head
    of the bed on 4- to 8-inch (10- to 20-cm) blocks
    to prevent the hernia from sliding upward.
    Surgery is indicated in about 15 of patients.

46
Management
  • Medical and surgical management of a
    paraesophageal hernia is similar to that for
    gastroesophageal reflux however, paraesophageal
    hernias may require emergency surgery to correct
    torsion (twisting) of the stomach or other body
    organ that leads to restriction of blood flow to
    that area.

47
DIVERTICULUM
  • A diverticulum is an outpouching of mucosa and
    submucosa that protrudes through a weak portion
    of the musculature. Diverticula may occur in one
    of the three areas of the esophagusthe
    pharyngoesophageal or upper area of the
    esophagus, the midesophageal area, or the
    epiphrenic or lower area of the esophagus or
    they may occur along the border of the esophagus
    intramurally.

48
  • The most common type of diverticulum, which is
    found three times more frequently in men than in
    women, is Zenkers diverticulum (also known as
    pharyngoesophageal pulsion diverticulum or a
    pharyngeal pouch). It occurs posteriorly through
    the cricopharyngeal muscle in the midline of the
    neck. It is usually seen in people older than 60
    years of age.

49
Clinical Manifestations
  • include difficulty swallowing, fullness in the
  • neck, belching, regurgitation of undigested
    food, and gurglingnoises after eating.
  • The diverticulum, or pouch, becomes filled with
    food or liquid. When the patient assumes a
    recumbent position, undigested food is
    regurgitated, and coughing may be caused by
    irritation of the trachea.
  • Halitosis and a sour taste in the mouth are also
    common because of the decomposition of food
    retained in the diverticulum.

50
Assessment and Diagnostic Findings
  • A barium swallow may be performed to determine
    the exact nature and location of a diverticulum.
  • Manometric studies are often performed for
    patients with epiphrenic diverticula to rule out
    a motor disorder.
  • Esophagoscopy usually is contraindicated because
    of the danger of perforation of the diverticulum,

51
Management
  • Because pharyngoesophageal pulsion diverticulum
    is progressive,the only means of cure is surgical
    removal of the diverticulum. During surgery, care
    is taken to avoid trauma to the common carotid
    artery and internal jugular veins.
  • Food and fluids are withheld until x-ray studies
  • show no leakage at the surgical site. The
    diet begins with liquids and progresses as
    tolerated.

52
PERFORATION
  • The esophagus is not an uncommon site of injury.
    Perforation may result from stab or bullet wounds
    of the neck or chest, trauma from motor vehicle
    crash, caustic injury from a chemical burn
    (described later), or inadvertent puncture by a
    surgical instrument during examination or
    dilation.

53
Clinical Manifestations
  • The patient has persistent pain followed by
    dysphagia. Infection,
  • fever, leukocytosis, and severe hypotension may
    be noted. In
  • some instances, signs of pneumothorax are
    observed.

54
Assessment and Diagnostic Findings
  • Diagnostic x-ray studies and fluoroscopy are used
    to identify the site of the injury.

55
Management
  • Because of the high risk of infection,
    broad-spectrum antibiotic therapy is initiated.
    A nasogastric tube is inserted to provide suction
    and to reduce the amount of gastric juice that
    can reflux into the esophagus and mediastinum.
    Nothing is given by mouth nutritional needs are
    met by parenteral nutrition. Parenteral nutrition
    is preferred to gastrostomy because the latter
    might cause reflux into the esophagus. Surgery
    may be necessary to close the wound, and
    postoperative nutritional support then becomes a
    primary concern.

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CHEMICAL BURNS
  • Chemical burns of the esophagus may be caused by
    undissolved medications in the esophagus. This
    occurs more frequently in the elderly than it
    does among the general adult population. A
    chemical burn may also occur after swallowing of
    a battery, which may release caustic alkaline.
    Chemical burns of the esophagus occur most often
    when a patient, either intentionally or
    unintentionally, swallows a strong acid or base

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RX
  • Esophagoscopy and barium swallow- to determine
    the extent and severity of damage.
  • The patient is NPO, and IV fluids adm
  • A NGT may be inserted by the physician.
  • Vomiting and gastric lavage are avoided to
    prevent further exposure of the esophagus to the
    caustic agent.

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RX
  • The use of corticosteroids to reduce inflammation
    and minimize subsequent scarring and stricture
    formation is of questionable value.
  • The value of the prophylactic use of antibiotics
    for these patients has also been questioned
  • For strictures that do not respond to dilation,
    surgical management is necessary.

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GASTROESOPHAGEAL REFLUX DISEASE
  • Some degree of gastroesophageal reflux (back-flow
    of gastric or duodenal contents into the
    esophagus) is normal in both adults and children.
    Excessive reflux may occur because of an
    incompetent lower esophageal sphincter, pyloric
    stenosis, or a motility disorder. The incidence
    of reflux seems to increase with aging.

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Clinical Manifestations(GERD)
  • pyrosis (burning sensation in the esophagus),
  • dyspepsia (indigestion), regurgitation,
  • dysphagia or odynophagia (difficulty swallowing,
  • pain on swallowing), hypersalivation, and
    esophagitis. The symptoms may mimic those of a
    heart attack.

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Assessment and Diagnostic Findings(GERD)
  • Diagnostic testing may include an endoscopy or
    barium swallow to evaluate damage to the
    esophageal mucosa.
  • Ambulatory 12- to 36-hour esophageal pH
    monitoring is used to evaluate the degree
  • of acid reflux.
  • Bilirubin monitoring (Bilitec) is used to measure
  • bile reflux patterns.

62
Management (GERD)
  • Management begins with teaching the patient to
    avoid situations that decrease lower esophageal
    sphincter pressure or cause esophageal
    irritation.
  • The patient is instructed to eat a low-fat diet
  • to avoid caffeine, tobacco, beer, milk, foods
    containing peppermint or spearmint, and
    carbonated beverages to avoid eating or drinking

63
Management (GERD)
  • 2 hours before bedtime to maintain normal body
    weight to avoid tight-fitting clothes to
    elevate the head of the bed on 6- to 8-inch (15-
    to 20-cm) blocks and to elevate the upper body
    on pillows.
  • If reflux persists, the patient may be given
    medications such as antacids or histamine
    receptor blockers. Proton pump inhibitors
    (medications that decrease the release of gastric
    acid,

64
Management (GERD)
  • Surgical management involves a fundoplication
    (wrapping of a portion of the gastric fundus
    around the sphincter area of the esophagus).
    Fundoplication may be performed by laparoscopy.

65
CANCER OF THE ESOPHAGUS
  • USA carcinoma of the esophagus occurs more than
    three times as often in men as in women. It is
    seen more frequently in African Americans than in
    Caucasians and usually occurs in the fifth decade
    of life. Cancer of the esophagus has a much
    higher incidence in other parts of the world,
    including China and northern Iran

66
  • cancer of the esophagus has been associated with
    ingestion of alcohol and with the use of tobacco.
    There seems to be an association between GERD and
    adenocarcinoma of the esophagus. People with
    Barretts esophagus (which is caused by chronic
    irritation of mucous membranes due to reflux of
    gastric and duodenal contents) have a higher
    incidence

67
Pathophysiology
  • Esophageal cancer is usually of the squamous cell
    epidermoid type however, the incidence of
    adenocarcinoma of the esophagus is increasing in
    the United States.
  • Tumor cells may spread beneath the esophageal
    mucosa or directly into, through, and beyond the
    muscle layers into the lymphatics.

68
Clinical Manifestations
  • Symptoms include dysphagia, initially with solid
    foods and eventually with liquids a sensation of
    a mass in the throat painful swallowing
    substernal pain or fullness and, later,
    regurgitation of undigested food with foul breath
    and hiccups.

69
  • As the tumor progresses and the obstruction
    becomes more complete, even liquids cannot pass
    into the stomach. Regurgitation of food and
    saliva occurs, hemorrhage may take place, and
    progressive loss of weight
  • Later symptoms include substernal pain,
    persistent hiccup, respiratory difficulty, and
    foul breath. The delay between the onset of early
    symptoms and the time when the patient seeks
    medical advice is often 12 to 18 months.

70
Assessment and Diagnostic Findings
  • new endoscopic techniques are being studied for
    screening and diagnosis of esophageal cancer,
    currently diagnosis is confirmed most often by
    EGD with biopsy and brushings.
  • Endoscopic ultrasound or mediastinoscopy
  • is used to determine whether the cancer has
    spread to the nodes and other mediastinal
    structures.

71
Medical Management
  • If esophageal cancer is found at an early stage,
    treatment goals may be directed toward cure
    however, it is often found in late stages, making
    relief of symptoms the only reasonable goal of
    therapy.
  • Treatment may include surgery, radiation,
    chemotherapy, or a combination of these
    modalities,

72
  • Standard surgical management includes a total
    resection of the esophagus (esophagectomy) with
    removal of the tumor plus a wide tumor-free
    margin of the esophagus and the lymph nodes in
    the area.
  • When tumors occur in the cervical or upper
    thoracic area, esophageal continuity may be
    maintained by free jejunal graft transfer, in
    which the tumor is removed and the area is
    replaced with a portion of the jejunum (Fig).

73
  • A segment of the colon may be used, or the
  • stomach can be elevated into the chest and the
    proximal section of the esophagus anastomosed to
    the stomach.
  • Tumors of the lower thoracic esophagus are more
    amenable to surgery than are tumors located
    higher in the esophagus, and gastrointestinal
    tract integrity is maintained by anastomosing the
    lower esophagus to the stomach.

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  • Surgical resection of the esophagus has a
    relatively high mortality rate because of
    infection, pulmonary complications, or leakage
    through the anastomosis.
  • Postoperatively, the patient will have a
    nasogastric tube in place that should not be
    manipulated. The patient is given nothing by
    mouth until x-ray studies confirm that
  • the anastomosis is secure and not leaking.

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Nursing Management
  • Intervention is directed toward improving the
    patients nutritional and physical condition in
    preparation for surgery, radiation therapy, or
    chemotherapy.
  • A program to promote weigh gain based on a
    high-calorie and high-protein diet, in liquid or
    soft form, is provided if adequate food can be
    taken by mouth.

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Nursing Management
  • informed about the nature of the postoperative
    equipment that will be used, including that
    required for closed chest drainage, nasogastric
    suction, parenteral fluid therapy, and gastric
    intubation.
  • After recovering from the effects of anesthesia,
    the patient is placed in a low Fowlers position,
    and later in a Fowlers position, to assist in
    preventing re- flux of gastric secretions.

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Nursing Management
  • The patient is observed carefully
    for-regurgitation and dyspnea. A common
    postoperative complication is aspiration
    pneumonia.
  • If jejunal grafting has been performed, the nurse
    checks for graft viability hourly for at least
    the first 12 hours. To make the graft visible,

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Nursing Management
  • Moist gauze covers the external portion of the
    graft. The gauze is removed briefly to assess the
    graft for color and to assess for the presence of
    a pulse by means of Doppler ultrasonography.
  • The nasogastric tube is removed 5 to 7 days after
    surgery, and a barium swallow is performed to
    assess for any anastomotic leak before the
    patient is allowed to eat.

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Nursing Management
  • Once feeding begins, the nurse encourages the
    patient to swallow small sips of water and,
    later, small amounts of pureed food.
  • After each meal, the patient remains upright for
    at least 2 hours to allow the food to move
    through the gastrointestinal tract.
  • If radiation is part of the therapy, the
    patients appetite is further depressed and
    esophagitis may occur.

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