Interventions for Clients with Esophageal Disorders

Interventions for Clients with Esophageal Problems

 Objectives

After studying this chapter, you should be able to:

1.   Explain the pathophysiology of gastroesophageal reflux disease (GERD).

2. Assess the client who is experiencing GERD.

3. Plan the nursing care for clients with GERD.

4. Develop a postoperative teaching plan for the client having a hiatal hernia repair.

5. Identify the differences in the incidence of esophageal cancer among cultural groups.

6. Describe the risk factors for esophageal cancer.

7. Analyze assessment data to determine common nursing diagnoses for the client with esophageal cancer.

8. Discuss the priorities for postoperative care of the client undergoing surgery for esophageal cancer.

9.     Plan community-based care for clients diagnosed with esophageal cance.

Etsophageal disorders affect approximately 546,000 peo­ple in the United States. One third of the population experi­ences symptoms associated with the reflux of stomach acid into the esophagus. Impaired gastroesophageal motility result­ing from achalasia or diverticula is responsible for 400,000 visits to health care providers annually (see the Cost of Care Box on p. 1193). The esophagus is a hollow, distensible muscular tube lo­cated behind the trachea that acts primarily as a conduit for food from the mouth to the stomach. It passes through the di­aphragm at the esophageal hiatus and extends to the gastro­esophageal junction. The esophagus is susceptible to a variety of inflammatory, structural, motor, and neoplastic disorders. Collaborative management involves medical and surgical therapies in addition to diet and lifestyle modifications. Nurses have a significant role in assisting clients in making the lifestyle changes necessary for the successful prevention and management of esophageal disorders.

GASTROESOPHAGEAL REFLUX DISEASE

 OVERVIEW

Esophageal reflux is defined as the backward flow of gas­trointestinal contents into the esophagus. Reflux produces its characteristic symptoms by exposing the esophageal mucosa to the irritating effects of gastric and/or duodenal contents, result­ing in inflammatory changes of the esophageal mucosa. A person with acute symptoms of inflammation is often described as having reflux esophagitis, a hallmark of gastroesophageal re­flux disease (GERD). Reflux esophagitis is graded according the extent and severity of the lesions.

 Pathophysiology

The following physiologic factors are implicated in the devel­opment of GERD (Tucker & Schumann, 1999):

·                          An incompetent lower esophageal sphincter

·                          Irritation from the refluxate

·   Abnormal esophageal clearance

·   Delayed gastric emptying

The reflux of gastric contents into the esophagus is normally prevented by the presence of two high-pressure areas that re­main relatively contracted in the resting phase. A 3-cm (1.2-inch) segment at the proximal end of the esophagus is called the upper esophageal sphincter (UES). Another 2- to 4-cm (0.8- to 1.6-inch) portion just proximal to the gastroesophageal junction is called the lower esophageal sphincter (LES). The function of the LES is supported by its anatomic placement in the ab­domen, where the surrounding pressure is significantly higher than in the low-pressure thorax. Sphincter function is also sup­ported by the acute angle (angle of His) that is formed as the esophagus enters the stomach. Esophageal reflux can occur when gastric volume or intra-abdominal pressure is elevated, when the sphincter tone of the LES is decreased, or when the LES undergoes inappropriate relaxation.

 

 

ESOPHAGEAL PROBLEMS

Cost of Care

·                              Ambulatory care for clients with Barrett’s esophagus costs approximately $103 per month, or $1241 per year.

·                              Clients with low-grade dysplasia (tissue changes) are three times as likely to have more than 3 endoscopies per year as compared to clients who do not have dysplasia.

·                              Endoscopies and clinic visits account for 31% and 5.9%, respectively, of the monthly medical costs.

·                              The medication costs per month for clients with Barrett’s esophagus is $65.

·                              Proton-pump inhibitors account for 64.6% of the total med­ication cost.

·                              Medications account for more than 50% of the total cost of care.

implications for Nursing

Prolonged gastrointestinal reflux leading to Barrett’s esopha­gus or disease results in a relatively high cost of care in terms of the need for health care services. Clients require ongoing monitoring by endoscopy for dysplastic changes in the mu-cosa, long-term medication adherence to control reflux, and primary care provider visits. Nurses can play an integral role in the prevention of gastrointestinal reflux by educating their clients about the risk factors for developing reflux, strategies for managing reflux, and the necessity of making lifestyle ad­justments that prevent esophageal damage.

 

   An individual experiencing reflux may be asymptomatic and relatively unaware that reflux is occurring. However, the esophagus has only a limited resistance to the damaging ef­fects of the acidic gastrointestinal (GI) contents. The pH of acid secreted by the stomach ranges from 1.5 to 2.0, whereas the pH of the distal esophagus is normally neutral (6.0 to 7.0). Repeated exposure of the esophageal mucosa to highly acid gastric secretions is associated with the development of ero­sive esophagitis.

Refluxed material is returned to the stomach by a combi­nation of gravity, saliva, and peristalsis. The effectiveness of the clearance mechanism is very important. An inflamed esophagus cannot eliminate the refluxed material as quickly or efficiently as a healthy one, and therefore the duration of exposure increases with each reflux episode.

Hyperemia (increased blood flow) and erosion occur in the esophagus in response to the chronic inflammation. Gastric acid and pepsin are responsible for the tissue injury. Minor capillary bleeding often accompanies the erosion, but frank hemorrhage is rare. During the process of healing, the body may substitute a columnar epithelium (Barrett’s 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 pre-malignant and is associated with an increased risk of cancer in 10% to 15% of clients with prolonged GERD (Sharma, 1999). The fibrosis and scarring that accompanies the healing process can produce esophageal stricture, resulting in a nar­rowing of the esophageal lumen. The stricture leads to pro­gressive difficulty in swallowing. Uncontrolled esophageal reflux also creates a risk for other serious complications such as esophageal ulceration, hemorrhage, and aspiration pneumonia. GERD has been implicated as one of the causes of adult-onset asthma, laryngitis, and dental deterioration.

 

TABLE55-1      FACTORS CONTRIBUTING TO DECREASED

LOWER ESOPHAGEAL SPHINCTER PRESSURE

Fatty foods

Caffeinated beverages, such as coffee, tea, and cola

Chocolate

Nicotine in cigarette smoke

Calcium channel blockers

Nitrates

Peppermint, spearmint

Alcohol

Anticholinergic drugs

High levels of estrogen and progesterone

Nasogastric tube placement

 Etiology

Current evidence suggests that GERD is a result of impaired LES function, which permits the reflux of gastric contents into the esophagus and the subsequent exposure of the esophageal mucosa to gastric contents from impaired esophageal clearance (Claussen, 1999). Currently, the role that hiatal hernia (see p. 1198) plays in the development of GERD is controversial, because each of these disorders often present independently of one another. Nighttime reflux tends to result in prolonged ex­posure of the esophagus to acid because recumbency tends to impair peristalsis and gravity clearance mechanisms.

Gastric distention caused by the ingestion of large meals or by conditions associated with delayed gastric emptying predis­pose the client to reflux. A number of individual factors, includ­ing certain foods and medications, have been identified as influ­encing the tone and contractility of the LES (Table 55-1). Clients who have a nasogastric tube often experience compro­mised 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., wearing tight belts, obesity, bend­ing over, and ascites) overcome the gastroesophageal pressure gradient maintained by the LES and allow reflux to occur.

Incidence/Prevalence

The incidence of GERD is approximately 2% to 3% per year and affects 25% to 35% of the population. Ten percent of the population reports experiencing symptoms of reflux daily, and 44% report experiencing symptoms once a month (Scott & Gelhot, 1999). Gastroesophageal reflux disease (GERD) can occur at any age but is more common in people over 45 years of age. The incidence of GERD may be underestimated because many people with mild disease relate the symptoms to episodes of stress or dietary indiscretion.

 

CULTURAL CONSIDERATIONS

? The prevalence of GERD is higher in females than in males and is found more often in Caucasians than in other ethnic groups. Severe esophagitis is more common in males than in females and is more prevalent in Caucasians than in African Americans.

 

 

 

 COLLABORATIVE MANAGEMENT  Assessment

■     HISTORY

The nurse assesses the client for a history of heartburn or atypical chest pain associated with the reflux of gastrointesti­nal contents. The client is assessed for dysphagia (difficulty swallowing) or odynophagia (painful swallowing), either of which can indicate the development of a stricture. The nurse further investigates whether the client has a history of newly diagnosed asthma, morning hoarseness, or pneumonia, which are suggestive of severe reflux reaching the pharynx or mouth and/or pulmonary aspiration.

■     PHYSICAL ASSESSMENT/CLINICAL
MANIFESTATIONS

The clinical manifestations of reflux may vary substantially in severity (Chart 55-1).

DYSPEPSIA. A diagnosis of GERD is made principally by a history of dyspepsia (also called pyrosis or heartburn), which is the characteristic symptom. Clients often describe this pain as a substernal or retrosternal burning sensation that tends to move up and down the chest in a wavelike fashion. If severe, the pain may radiate to the neck or jaw or may be re­ferred to the back. The pain typically worsens when the client bends over, strains, or is in a recumbent position.

With severe GERD, the pain occurs after each meal and persists for 20 minutes to 2 hours. Clients usually experience prompt relief by ingesting fluids or antacids or by maintain­ing an upright posture. Some clients experience atypical chest pain, which mimics angina and needs to be carefully differ­entiated from cardiac disease.

REGURGITATION. Regurgitation, which is associated with neither belching nor nausea, is another common symp­tom. The client reports the occurrence of warm fluid traveling up the throat. If the fluid reaches the level of the pharynx, the client notes a sour or bitter taste in the mouth. This effortless regurgitation can even occur when the client is in an upright position. The danger of aspiration is increased if regurgitation occurs when the client is in a recumbent position.

If the client experiences regurgitation, the nurse carefully auscultates the chest for crackles, which is an indication of as­sociated aspiration. The nurse assesses for coughing, hoarse­ness, or wheezing at night, which may be related to recumbent regurgitation. Assessment for bronchitis may be necessary in clients experiencing long-term regurgitation.

 

KEY FEATURES of Gastroesophageal Reflux Disease

Dyspepsia (heartburn or pyrosis)

Regurgitation (may lead to aspiration or bronchitis)

Coughing, hoarseness, or wheezing at night

Water brash

Dysphagia

Odynophagia (painful swallowing)

Chest pain

Belching

Flatulence

 

HYPERSALIVATION. A reflex salivary hypersecretion known as water brash occurs in response to reflux. Water brash must be carefully distinguished from regurgitation. The client reports a sensation of fluid in the throat, but unlike with regurgitation, there is no bitter or sour taste.

DYSPHAGIA AND ODYNOPHAGIA. Chronic GERD can involve dysphagia (difficulty in swallowing). Dysphagia may be the presenting symptom in 33% of clients with GERD. This symptom is usually fairly mild; it is not progressive and oc­curs with the first swallow of each meal. Dysphagia does not in­terfere with oral nutrition and does not produce weight loss. Careful assessment is required if a client reports progressive or persistent dysphagia, because this usually indicates the develop­ment of a stricture or cancer. The nurse assesses the following:

•   The degree of dysphagia

•  Whether dysphagia occurs with the ingestion of solids, liquids, or both

•  Whether dysphagia is intermittent or occurs with each swallowing effort

Odynophagia (painful swallowing) is a possible symptom of GERD but is relatively rare in people with uncomplicated reflux disease. Severe and long-lasting chest pain may be present if spasms occurring in the esophagus cause the mus­cle to contract with excess force. The resulting pain can be ag­onizing and last for hours.

OTHER CLINICAL MANIFESTATIONS. Eructation (belching), flatulence (gas), or bloating after eating are other common complaints. Nausea and vomiting occur infre­quently, and unplanned weight loss is rare.

 RADIOGRAPHIC ASSESSMENT

No single test is considered to be a gold standard for diagnos­ing GERD. A barium swallow can be used to rule out compli­cations associated with GERD or to evaluate dysphagia, but it is not sensitive enough to be diagnostic. The most accurate method of diagnosing gastroesophageal reflux disease (GERD) is 24-hour pH monitoring; this involves placing pH probes 2 inches (5 cm) above the lower esophageal sphincter (LES). A barium swallow with fluoroscopy then outlines the structure of the esophagus and its peristaltic patterns. Twenty-four hour am­bulatory pH monitoring is widely used but is helpful only in evaluating acid reflux. Endoscopy is useful in diagnosing or evaluating reflux esophagitis or in monitoring complications such as Barrett’s esophagus. During endoscopy, tissue samples can be obtained for biopsy, and strictures can be dilated (see Chapter 53).

 

OTHER DIAGNOSTIC ASSESSMENT

The health care provider orders esophageal manometry, or motility testing, when the diagnosis is uncertain. Water-filled catheters are inserted via the client’s nose or mouth and are connected to transducers that record pressures from various sites in the esophagus as the catheters are withdrawn. Manom­etry quantifies the resting pressure of the LES and helps to evaluate sphincter competence, but when used alone it is not sensitive or specific enough to establish a diagnosis of GERD. In Bernstein’s test, an acidic solution is infused via a tube inserted  into  the  distal  esophagus.   Clients  with  normal esophageal mucosa experience no symptoms when acid is in­fused, but clients with esophagitis experience immediate heartburn.

Scintigraphy involves preloading the stomach with a liquid radioisotope via the mouth or a tube. Scintillation counts are performed over the lower esophagus and are compared with counts obtained over the stomach. If a client is experiencing frequent reflux, the radioisotope will be refluxed back into the esophagus, which significantly elevates the scintillation counts over the lower esophageal region. Scintigraphy may be used in conjunction with pH monitoring.

 Interventions

Interventions begin with thorough teaching that GERD is a chronic condition that warrants ongoing management. This knowledge base is essential for a client’s understanding of and adherence to the prescribed regimen of drugs, diet ther­apy, and lifestyle modifications.

NONSURGICAL MANAGEMENT. The goals of treat­ment for GERD are the relief of symptoms, treatment of esophagitis, and prevention of complications such as stric­tures or Barrett’s esophagus. Although GERD can be con­trolled by diet therapy, education, lifestyle changes, and drug therapy, it is important to note that, even after the esophagitis is healed, 40% to 80% of clients relapse in 6 months after their medication is discontinued.

DIET THERAPY. Diet therapy is used to relieve symptoms in clients with relatively mild GERD. In collaboration with the dietitian, the nurse explores the client’s basic meal pat­terns and food preferences. The nurse and dietitian work with both the client and the family to plan modifications that may decrease reflux symptoms. For adherence at home to be suc­cessful, it is essential that family members who do the shop­ping and cooking be included in this discussion.

In conjunction with the dietitian, the nurse counsels the client to limit or eliminate foods that decrease LES pressure. The client should also restrict spicy and acidic foods (e.g., or­ange juice, tomatoes) until esophageal healing can occur, be­cause these foods irritate the inflamed tissue and cause heart­burn (Goldsmith, 1998).

Because large meals increase the volume of and pressure in the stomach and delay gastric emptying, the nurse or dietitian instructs the client to eat four to six small meals each day rather than three large ones. Carbonated beverages should also be avoided because they increase pressure in the stomach. Clients are encouraged to avoid evening snacks and to eat no food for at least 3 hours before going to bed, because reflux episodes are most damaging at night. Clients may have the most difficulty adhering to the restriction of evening snacks. The nurse also ad­vises the client to eat slowly and chew thoroughly to facilitate digestion and prevent eructation (belching). The client is en­couraged to investigate which particular diet changes best re­duce the frequency and severity of symptoms.

CLIENT EDUCATION. The nurse educates the client about the risk factors for the development of reflux, including con­tributing lifestyle factors. Lifestyle factors that can exacerbate the disease are reviewed, and the client is counseled on ways to eliminate them. The nurse also educates the client regarding the need for ongoing monitoring, particularly if the client has developed strictures, ulcerations, or Barrett’s esophagus.

LIFESTYLE CHANGES. The control of GERD involves some lifestyle adjustments on the part of the client. For ex­ample, he or she is instructed to elevate the head of the bed by 8 to 12 inches for sleep to prevent nighttime reflux. In addi­tion, he or she is instructed to sleep in the left lateral decubi-tus position to minimize the effects of nighttime episodes of reflux (see the Evidence-Based Practice for Nursing box be­low). Nighttime reflux is extremely common, and infrequent swallowing in combination with a recumbent position signif­icantly impairs esophageal clearance. Although wooden blocks have traditionally been recommended to elevate the head of the bed, foam wedges may also achieve satisfactory results. The client or the client’s spouse or partner may find elevation of the bed unacceptable at first. The nurse empha­sizes the importance of this intervention and investigates all possible approaches for achieving compliance (Chart 55-2).

For clients with a history of smoking, the nurse explores the possibility and means of smoking cessation and makes the appropriate referrals. The nurse explains that smoking causes a prompt and significant drop in LES pressure and optimally should be stopped. The nurse also explores the client’s normal pattern and amount of alcoholic beverage use. The client is taught about the effects of alcohol on LES sphincter pressure. The nurse can assist the client in finding appropriate alcohol cessation programs if needed.

 

EVIDENCE-BASED PRACTICE

The purpose of this study was to investigate the influence of body position during sleep on recumbent reflux in 10 clients with gastroesophageal reflux disease. The 10 subjects (3 fe­male, 7 male) were fed a standardized, high-fat dinner and bedtime snack. A single-channel pH probe was placed 5 cm above the lower esophageal sphincter (LES) in each client to measure the percentage of reflux episodes (pH <4) that oc­curred during four sleeping positions. A body position sensor taped to the client’s sternum recorded spontaneous changes in posture during sleep.

The right lateral position was associated with the greatest percentage of time the pH remained under 4 and longer esophageal acid clearance when compared to the left, supine, and prone positions. The supine position resulted in a greater overall number of gastroesophageal reflux episodes that oc­curred within 1 minute of assuming this position. This study determined that the preferred sleeping position for clients with gastroesophageal reflux is the left lateral position.

Critique. Although the sample size was small, this was the first study to examine the effects of sleeping positions on re­cumbent reflux in clients with gastroesophageal reflux.

Implications for Nursing. Previous research supports the theory that body position influences gastroesophageal reflux. Nurses can incorporate information concerning sleeping posi­tion into their teaching plan for clients faced with damaging nighttime reflux. In addition to elevating the head of the bed, clients can be instructed to lie in the left lateral position for sleep to reduce the number of reflux episodes and the length of time the esophageal mucosa is exposed to acidic contents.

 

 

CLIENT EDUCATION GUIDE

Lifestyle Modifications to Control Reflux

 

·                          Eat four to six small meals a day.

·   Limit or eliminate fatty foods, coffee, tea, cola, and chocolate.

·   Reduce or eliminate from your diet any food or spice that causes pain.

·   Limit or eliminate alcohol and tobacco.

·   Do not snack in the evening, and take no food for 2 to 3 hours before you go to bed.

·   Eat slowly, and chew your food thoroughly to reduce belching.

·                          Remain upright for 1 to 2 hours after meals, if possible. Elevate the head of your bed 8 to 12 inches using wooden blocks or a foam wedge. Never sleep flat in bed.

·    If you are overweight, lose weight. Do not wear constrictive clothing.

·                          Avoid heavy lifting, straining, and working in a bent-over position.

If the client is obese, the nurse collaborates with the dieti­tian to examine approaches to weight reduction. Decreasing intra-abdominal pressure often reduces reflux symptoms.

Other lifestyle factors cause increased abdominal pressure, and the nurse explores these with the client. Wearing con­strictive clothing, lifting heavy objects or straining, and work­ing in a bent-over or stooped position should be avoided. The nurse emphasizes that these general adaptations are an essen­tial and effective component of disease management and can produce prompt results in uncomplicated cases.

DRUG THERAPY. Some medications can cause reflux. Therefore the nurse, in conjunction with the primary health care provider, explores the possibility of eliminating from the client’s regimen those medications implicated in reflux. Three principles guide drug therapy for gastroesophageal reflux: (1) to inhibit gastric acid secretion, (2) to accelerate gastric emp­tying, and (3) to protect the gastric mucosa (Chart 55-3).

Antacids. In uncomplicated cases of GERD, antacids are effective for occasional episodes of heartburn. Antacids act by elevating the pH level of the gastric contents, thereby deacti­vating pepsin. They are inadequate for the control of frequent symptoms because their duration of action is too short and their nighttime effectiveness is minimal.

Antacids containing aluminum hydroxide or magnesium hy­droxide may be used. Maalox and Mylanta consist of a combi­nation of these two agents, and clients often tolerate them bet­ter because they produce fewer side effects such as constipation and diarrhea. The nurse instructs the client to take the antacid 1 hour before and 2 to 3 hours after each meal. Some antacids are prepared as double-strength (DS) suspensions or tablets. The advantage of DS preparations is that the client can take a smaller amount of the drug. For example, 30 mL of regular My­lanta equals 15 mL of Mylanta-II (DS preparation).

Gaviscon, a combination of aluminum hydroxide and mag­nesium carbonate, is a commonly used and very effective med­ication for GERD. It forms a viscous foam that floats on top of the gastric contents and theoretically decreases the incidence of reflux. If reflux occurs, the foam enters the esophagus first and buffers the acid in the refluxed material. The nurse re­minds the client to take this drug when food is in the stomach.

Histamine Receptor Antagonists. Histamine blockers, such as famotidine (Pepcid), ranitidine (Zantac), cimetidine (Tagamet), and nizatidine (Axid) are the main pharmacologic means of inhibiting gastric acid secretion. With histamine recep­tor antagonists available over the counter (OTC) and widely ad­vertised for heartburn, many clients self-medicate before seeking professional assistance from their health care provider. When clients who have self-medicated with OTC preparations experi­ence uncontrolled symptoms, the health care provider usually prescribes a higher dose of a histamine receptor antagonist.

Cimetidine (Tagamet) is not used as often as the longer-acting preparations. It has an inhibitory effect on the elimina­tion of certain other medications, and therefore significant drug interactions can occur in clients taking warfarin, theo-phylline, phenytoin, nifedipine, or propranolol. Ranitidine and the other preparations are longer acting, and less frequent dos­ing is necessary. They also appear to produce fewer side ef­fects and are safe for long-term administration. Although these drugs do not affect the occurrence of reflux directly, they do reduce gastric acid secretion, provide symptomatic improve­ment, and support healing of the inflamed esophageal tissue.

The proton pump inhibitors, such as omeprazole (Prilosec), lansoprazole (Prevacid), and rabeprazole (Aciphex), demon­strate effective, long-acting inhibition of gastric acid secretion. They are typically reserved for the treatment of severe GERD that is refractory to treatment with histamine blockers, and they play an important role in maintaining the remission of both GERD and Barrett’s esophagus. These potent drugs can reduce gastric acid secretion by about 90% over a 24-hour period and can be given in a single daily dose. If once-a-day dosing fails to control symptoms, twice-a-day dosing is appropriate (Sharma, 1999). For example, omeprazole (Prilosec) is usually prescribed as a 20-mg oral dose once a day for 4 to 8 weeks. Complete heal­ing of esophagitis is seen in 80% to 97% of clients (Tucker & Schumann, 1999). Proton pump inhibitors promote rapid tissue healing, but recurrence is common when the drug is stopped.

Other Drugs. Prokinetic drugs are used to accelerate gas­tric emptying and improve lower esophageal sphincter (LES) pressure and esophageal peristalsis. The health care provider may add bethanechol (Urecholine) or metoclopramide (Reglan) to the drug regimen for clients who experience severe and on­going symptoms of reflux.

Bethanechol is a cholinergic drug; it increases the secre­tion of gastric acid and usually requires the simultaneous ad­ministration of a histamine receptor antagonist and antacids. Bethanechol is usually prescribed in 25-mg doses four times a day. The nurse teaches the client to take bethanechol 30 to 60 minutes before meals and warns the client about the typi­cal side effects, which include abdominal cramping, diarrhea, increased salivation, and urinary urgency.

The primary action of metoclopramide is to increase the rate of gastric emptying. It does not affect gastric acid secre­tion or directly heal esophageal tissue. Its use is also associ­ated with a high incidence of neurologic and psychotropic side effects such as fatigue, anxiety, ataxia, and hallucina­tions. Long-term use is not recommended.

SURGICAL MANAGEMENT. Antireflux surgery is usu­ally indicated for otherwise healthy clients who have failed to respond to medical treatment or to demonstrate complications related to GERD or for whom the cost of long-term drug therapy is prohibitive. Various surgical procedures may be used. The three major surgical procedures are Nissen fundoplica-tion, the Hill repair, and the Belsey repair (Figure 55-1).

In each of these procedures, the surgeon wraps and sutures the gastric fundus around the esophagus, which anchors the LES area below the diaphragm and reinforces the high-pres­sure area. For a more complete description of the three major procedures, see Operative Procedures (Hiatal Hernia), p. 1202.

The Client Care Plan on pp. 1199 and 1200 outlines the nursing care of clients undergoing esophageal surgery. Clients who have surgery are encouraged to continue following the basic antireflux regimen of antacids and diet therapy, because the rate of recurrence is significant.

Placement of the synthetic Angelchik prosthesis is also used for clients with severe reflux. This surgical procedure is associated with fewer long-term problems with achalasia (failure of the lower esophageal muscles and sphincter to re­lax properly). The surgeon performs a laparotomy and ties a C-shaped silicone prosthesis filled with gel around the distal esophagus (Figure 55-2). The prosthesis anchors the LES in the abdomen and reinforces sphincter pressure. Dysphagia is the primary complication of this procedure.

 OVERVIEW

The esophageal hiatus is the opening in the diaphragm through which the esophagus passes from the thorax to the abdomen. Hiatal hernias, also called diaphragmatic hernias, involve the protrusion of the stomach through the esophageal hiatus of the diaphragm into the thorax. Clients with hiatal hernias may be completely asymptomatic or may experience daily symptoms similar to those of clients with GERD.

 Pathophysiology

The two major types of hiatal hernias are sliding hernias and paraesophageal (rolling) hernias.

 SLIDING HERNIA

Sliding hernias are the most common type of hernia and ac­count for 90% of the total number of hiatal hernias. The esophagogastric junction and a portion of the fundus of the stomach slide upward through the esophageal hiatus into the thorax (Figure 55-3). The hernia generally moves freely and slides into and out of the thorax during changes in position or intra-abdominal pressure. Although volvulus (twisting) and obstruction do occur rarely, the major concern in a client with a sliding hernia is the development of esophageal reflux and its complications. The development of reflux appears to be re­lated to chronic exposure of the lower esophageal sphincter (LES) to the low pressure of the thorax, which significantly reduces the effectiveness of the LES. Symptoms associated with LES pressure are worsened by positions that favor re­flux, such as bending or lying supine.

Figure 55-1    •    Nissen fundoplication for gastroesophageal re­flux disease or hiatal hernia repair.

ROLLING HERNIA

With paraesophageal hernias, the gastroesophageal junction re­mains in its normal intra-abdominal location, but the fundus (and possibly portions of the stomach’s greater curvature) roll through the esophageal hiatus and into the thorax beside the esophagus (see Figure 55-3). The herniated portion of the stom­ach may be small or quite large; in rare cases, the stomach com­pletely inverts into the thorax. Reflux is rarely a concern because the LES remains anchored below the diaphragm, but the risks of volvulus, obstruction, and strangulation are high. The develop­ment of iron deficiency anemia is common, because slow bleed­ing secondary to venous obstruction causes the gastric mucosa to become engorged and ooze. Significant bleeding or hemor­rhage is rare.

 

 

 

 

 

 

 Etiology

Sliding hiatal hernias are believed to develop from muscle weakening in the esophageal hiatus, which loosens the esophageal supports and permits the lower portion of the esophagus to rise into the thorax. Congenital weaknesses, trauma, obesity, or surgery may also play a significant role. The development of the hernia is the result of the combined effects of weakened support structures and prolonged in­creases in abdominal pressure.

Muscle weakening does not appear to cause paraesoph-ageal hernias. Instead, it is theorized that the stomach is not properly anchored below the diaphragm, and the hernia re­sults from an anatomic defect rather than a structural weak­ness. Paraesophageal hernias can also be caused by previous esophageal surgeries, including sliding hernia repair.

 Incidence/Prevalence

Hiatal hernia is one of the more common disorders that affect the upper gastrointestinal tract, and it affects women more of­ten than men. Hiatal hernias have been reported in up to 20% of adults (Crawford, 1999).

 CONSIDERATIONS FOR OLDER ADULTS

Ebb The incidence of sliding hiatal hernias increases with age in both genders and reaches a prevalence of approximately 60% in the sixth decade of life. As many as 80% of clients with hiatal hernias are asymptomatic or experience only mild, transient symptoms associated with reflux.

 COLLABORATIVE MANAGEMENT

 Assessment

The nurse carefully assesses for heartburn, regurgitation, pain, dysphagia, and belching. An assessment of the client’s general physical appearance and nutritional status is also included. The nurse notes the location, onset, duration, quality, and aggravat­ing and alleviating factors associated with the presence of pain. The primary symptoms of sliding hiatal hernias are associated with reflux. The nurse auscultates the thorax and lungs, as pul­monary symptoms similar to asthma may be triggered by episodes of aspiration, particularly at night. A detailed history is crucial in attempting to differentiate angina from noncardiac chest pain due to gastroesophageal reflux. Symptoms resulting from hiatal hernia typically worsen after a meal or when the client is in a recumbent position (Chart 55-4).

In clients with paraesophageal (rolling) hernias, the nurse assesses for symptoms related to the stretching or displace­ment of thoracic contents by the hernia. Clients may report a feeling of fullness after eating and may even experience breathlessness or a feeling of suffocation if the hernia inter­feres with breathing. Some clients 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. Para­esophageal hernias are usually clearly visible, and sliding her­nias can often be observed as the client is moved through a se­ries of positions that increase intra-abdominal pressure.

Clients with sliding hernias usually experience symptoms of reflux. Therefore any or all of the diagnostic tests used for gastroesophageal reflux disease (GERD) may be used to fully evaluate the extent of reflux and the degree of esophageal damage (see Other Diagnostic Assessment [GERD], p. 1194).

 

 Interventions

Clients with hiatal hernias may be managed either medically or surgically. The health care provider’s choice of manage­ment is based on the severity of the client’s symptoms and the risk of serious complications. Sliding hiatal hernias are most commonly treated medically. Large paraesophageal hernias can become strangulated or obstructed; therefore early surgi­cal repair is encouraged.

NONSURGICAL MANAGEMENT. The interventions for clients with hiatal hernia closely follow those outlined for clients with GERD and include drug therapy, diet therapy, lifestyle modifications, and client education. The health care provider typically prescribes antacids and histamine receptor antagonists, such as ranitidine (Zantac), in an attempt to con­trol reflux and its symptoms.

Diet therapy is also an integral part of the conservative management of hiatal hernia and follows the guidelines dis­cussed earlier for GERD, p. 1195. The client is encouraged to avoid eating in the late evening and to avoid foods associated with reflux. In collaboration with the dietitian, the nurse works with the client to modify the diet to reduce body weight (if ap­propriate), because obesity increases intra-abdominal pressure and worsens both the hernia and the symptoms of reflux.

The nurse carefully explains the underlying condition to increase the client’s understanding of the disorder and in­crease adherence to the treatment regimen. Teaching about positioning, as described earlier for GERD (p. 1195) is also extremely important. It is essential that clients:

•  Sleep at night with the head of the bed elevated 8 to 12
inches

•  Remain upright for several hours after eating

•  Avoid straining or excessive vigorous exercise

•  Refrain from wearing clothing that is tight or constric-
tive around the abdomen

SURGICAL MANAGEMENT. The physician usually sched­ules surgery when the risk of complications is high or when damage from chronic reflux becomes severe.

 

 

 

 

PREOPERATIVE CARE. If the surgery is not urgent, the surgeon encourages clients who are overweight to lose weight before surgery. Clients are advised to quit or significantly re­duce smoking. As part of preoperative teaching, the nurse re­inforces the surgeon’s instructions and prepares the client for the postoperative course. Before developing the teaching plan, the nurse must know which surgical approach is planned. For the thoracic surgical ap­proach, for example, the client is taught about chest tubes. The nurse also informs the client 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. The nurse also in­structs the client about techniques for effective deep breathing and use of the incentive spirometer. These measures are essen­tial to prevent postoperative respiratory complications. The high incision makes deep breathing extremely painful for the client. The nurse educates the client concerning the aspects of postop­erative pain and assures the client that adequate postoperative analgesia will be administered.

OPERATIVE PROCEDURES. Although several hiatal hernia repair procedures are in use, each involves reinforce­ment of the lower esophageal sphincter (LES) through some degree of fundoplication. The surgeon wraps a portion of the stomach fundus around the distal esophagus to anchor it and reinforce the LES. The eventual recurrence for either type of hernia following surgical repair is 10% to 15% over 5 years (Ferguson, 1997).

The Nissen repair is the most commonly used procedure (see Figure 55-1) for hiatal hernia repair. An abdominal ap­proach is usually chosen. The surgeon wraps the fundus a full 360 degrees around the lower esophagus. The sphincter rein­forcement is tight and usually controls reflux effectively. Lap-aroscopic Nissen fundoplication (LNF) is a relatively new surgical technique that involves the creation of an antireflux valve or fundoplication laparoscopically through 5 ‘/₂-inch in­cisions in the abdomen. The fundus is then wrapped 360 de­grees around the LES to strengthen it (Vaca et al., 1998).

In the Hill repair, an abdominal approach is also used, but the fundoplication is wrapped 180 degrees around the esoph­agus. The angle of His is restructured to accentuate the angle at which the esophagus enters the stomach. The Belsey repair usually involves a 280-degree esophageal wrap and uses a thoracic approach.

Surgeons do not agree about which surgical repair is most appropriate or effective, because each procedure has unique advantages and disadvantages. For example, the laparoscopic Nissen fundoplication is associated with all the risks of a ma­jor surgery; pneumonia, myocardial infarction, wound infec­tion, and bleeding (Vaca et al., 1998).

POSTOPERATIVE CARE. Postoperative care following hiatal hernia repair closely follows that required after any esophageal surgery (see the Client Care Plan on pp. 1199 and 1200). The nurse carefully assesses for complications of fun­doplication surgery and reports their occurrence to the physi­cian (Chart 55-5).

Respiratory Care. The primary focus of postoperative care is the prevention of respiratory complications. The nurse or assistive nursing personnel elevates the head of the client’s bed at least 30 degrees to lower the diaphragm and facilitate lung expansion. The client is assisted out of bed and is ambu­lated as soon as possible. The incision must be supported dur­ing coughing to reduce pain and to prevent excessive strain on the suture line, especially with obese clients.

 

BEST PRACTICE/or

Assessment of Postoperative Complications Related to

Fundoplication Procedures

ASSESSMENT FINDINGS

The client has difficulty swallowing when oral feeding begins.

The client has difficulty belching to relieve distention.

The client experiences dyspnea, chest pain, and/or fever.

The client experiences nausea, vom­iting, and/or abdominal distention. The nasogastric tube does not drain.

 

Incentive spirometry and deep breathing are routinely used after surgery to maintain patency of the airways. Adequate analgesia is essential for client compliance and should be ad­ministered as needed. Clients with a smoking history or chronic airway limitation (chronic obstructive pulmonary dis­ease, asthma) require more aggressive respiratory manage­ment by the respiratory therapist to prevent atelectasis and pneumonia. Clients with large hiatal hernias are at high risk for developing respiratory complications.

Nasogastric Tube Management. Postoperative man­agement also involves the care of the nasogastric (NG) tube. Inserting a large-diameter NG tube during surgery prevents the fundoplication wrap from becoming too tight around the esophagus. The nasogastric drainage is initially dark brown with old blood but should become normal yellowish green within the first 8 hours after surgery. The nurse checks every 4 to 8 hours for proper placement of the tube in the stomach. The NG tube should be properly anchored so it cannot be dis­placed, because it cannot be safely reinserted without risking perforation of the incision.

Frequent assessment of the patency of the tube is essential to keep the stomach decompressed; this prevents retching or vomiting, which can strain or rupture the stomach sutures. Because the tube is irritating, the nurse or assistive nursing personnel provides frequent oral hygiene. The nurse also as­sesses the client’s hydration status regularly, including accu­rate measures of intake and output. Adequate fluid replace­ment helps to thin respiratory secretions.

Nutritional Care. The client may begin oral intake with clear fluids after peristalsis is re-established or in an effort to stimulate peristalsis. Some surgeons create a temporary gas-trostomy for feeding to allow for undisturbed healing of the repair. The client gradually progresses to a near-normal diet during the first 6 weeks. A few foods, such as 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.

The nurse carefully supervises the first oral feedings, be­cause temporary dysphagia is common. Persistent dysphagia usually indicates that the fundoplication is too tight, and dila­tion may be required.

Another common complication of fundoplication surgery is the gas bloat syndrome, in which clients are unable to vol­untarily eructate (belch). The syndrome is usually temporary but may persist. The nurse teaches the client to avoid drinking carbonated beverages, eating gas-producing foods (especially high-fat foods), chewing gum, and drinking with a straw.

Many clients acquire the habit of aerophagia (air swallow­ing) from attempting to reverse or clear acid reflux. The nurse teaches these clients to consciously relax before and after meals, eat and drink slowly, and chew all food thoroughly.

Air in the stomach that cannot be removed by belching can be extremely uncomfortable. Frequent position changes and ambulation are effective interventions for eliminating air from the gastrointestinal tract.

P Community-Based Care

Clients undergoing one of the three major surgical repairs re­quire activity restrictions during the 4- to 6-week postopera­tive recovery period. For laparoscopic surgery, activity is typ­ically restricted for a shorter time, and the client can return to his or her usual lifestyle more quickly. For long-term man­agement, the nurse teaches the client and family about appro­priate diet modifications, but the use of stool softeners or bulk laxatives is recommended for the first postoperative weeks until healing is complete. The nurse instructs the client to avoid straining and prevent constipation.

The client is taught to inspect the healing incision daily and to notify the physician or health care provider if swelling, redness, tenderness, discharge, or fever occurs. The nurse ad­vises the client to avoid contact with people with respiratory infections and to contact the physician if symptoms of a cold or influenza develop. Persistent coughing can cause the inci­sion or the fundoplication to dehisce. The client is also ad­vised to avoid smoking.

The nurse and dietitian educate the entire family or signif­icant other about diet. Full support is essential for the client to successfully modify the size and timing of meals. Relatively few ongoing diet restrictions are needed, but overeating or eating the wrong types of foods can produce discomfort if the client cannot belch. The client avoids foods that produce dis­comfort, and the nurse encourages cautious experimentation with new foods. The nurse instructs the client to report the re­currence of reflux symptoms to the health care provider.

Although severe surgical complications are relatively rare, conditions such as gas bloat syndrome and dysphagia are common and may persist. The nurse helps the client prepare for these problems and for the potential that reflux rriay not be completely controlled or may occur again. Although surgery controls the condition, a cure is rare, and lifestyle modifica­tions need to be ongoing.

 

ACHALASIA

 OVERVIEW

   Achalasia is an esophageal motility disorder in which the lower esophageal sphincter (LES) fails to relax properly with swallowing and in which the normal peristalsis of the esoph­agus is replaced with abnormal contractions. It is character­ized by chronic and progressive dysphagia. Regurgitation of ingested food may also occur, especially at night, resulting in aspiration. If left untreated, progressive dysphagia can result in weight loss. Chest pain is experienced by one third of clients with the disorder.

Achalasia is thought to result from esophageal denervation (loss of nerve impulse passage). The exact cause of denerva­tion is unknown. A genetic basis to the disorder has been pro­posed as suggested by occasional familial clustering and phe-notype (observable characteristics) association.

Over time, peristaltic failure plus spasm can produce a massively dilated esophagus, which further slows food pas­sage. Achalasia is an uncommon disorder that usually mani­fests itself in young adulthood. Both genders appear to be equally affected. Approximately 5% to 10% of individuals with this disorder develop esophageal squamous cell carci­noma (Crawford, 1999). Complications of achalasia also in­clude esophageal candidiasis, lower esophageal diverticula, airway obstruction, and aspiration pneumonia.

 COLLABORATIVE MANAGEMENT B> Assessment

The nurse assesses for the primary symptoms of achalasia, such as dysphagia and regurgitation of solids, liquids, or both. The client is asked about the presence of chest pain associated with these symptoms.

Achalasia is often a chronic condition. The symptoms worsen over time, which poses an increased threat to health and functioning as the disorder progresses. The nurse ques­tions the client about factors that aggravate the symptoms (e.g., body position or diet changes) as well as medications or home treatments that relieve the symptoms. The client is asked about a history of previous esophageal surgery or trauma, which compound the progressive dysphagia. Respira­tory history and current respiratory-associated symptoms are particularly important with regard to their direct relationship to reflux, regurgitation, and aspiration.

To determine the effect of the esophageal symptoms, the nurse obtains a nutritional history, including dietary habits, food tolerances, and weight loss. The nurse also notes the presence of halitosis (foul mouth odor), which can be caused by the regurgitation of previously ingested food. The nurse auscultates the lungs for adventitious sounds secondary to pulmonary aspiration of retained saliva and food. The nurse or assistive nursing personnel weighs the client and compares this weight with the client’s usual weight.

A chest x-ray study reveals a distorted and dilated tubular esophagus, the absence of a gastric air bubble and, occasion­ally, a tubular mediastinal mass next to the aorta. A barium swallow reveals esophageal dilation with a persistent beaklike narrowing at the terminal esophagus—the hallmark of a non-relaxing LES. Esophageal manometry typically reveals an el­evated resting LES pressure and incomplete sphincter relax­ation when the client swallows. Endoscopy is used to evaluate the appearance of the esophageal mucosa, especially for changes associated with cancer or the presence of Candida.

 Interventions

The symptoms associated with achalasia can be treated with a variety of approaches. A combination of dietary measures, pharmacologic agents, esophageal dilation and surgery are used.

DRUG AND DIET THERAPY. Mild cases of achalasia can be managed with calcium channel blockers or nitrates to re­duce LES pressure. Drug therapy is given for symptom relief and is not recommended as an alternative to more definitive therapy.

The nurse advises the client to experiment with changes in diet because they can often ease the pressure and reflux asso­ciated with achalasia. The nurse discusses with the client any food habits he or she has noted that aggravate or relieve the symptoms. Semisoft foods are often better tolerated, as are warm foods and liquids. Eating four to six smaller meals rather than three large meals during the day facilitates the passage of food. The nurse collaborates with the dietitian for additional suggestions about diet changes and nutritional balance. Nocturnal reflux of foods and liquids from the dilated esophagus into the hypopharynx and oral cavity often can be prevented if the client sleeps with the head of the bed elevated or in a semisitting position. The nurse also advises the client to experiment with various changes in position while eating, because such changes can reduce pressure sensations during meals. Some clients benefit from arching the back while swal­lowing. The nurse cautions the client to avoid wearing re­strictive clothing, which can increase esophageal pressure and regurgitation.

ESOPHAGEAL DILATION. More severe cases of achala­sia require dilation of the LES. The traditional treatment in­volves the passage of progressively larger sizes of esophageal bougies (dilators). Balloon dilation of the esophagus (using polyurethane balloons on a catheter) is considered the most effective treatment for achalasia. The procedure is performed on an ambulatory care basis. Typically, pneumatic dilators are positioned across the esophageal junction with fluoroscopy and local anesthesia. The balloon, which is filled with air or water, is inflated to a predetermined level for 30 to 60 seconds (Figure 55-4). This method lowers the basal LES pressure by tearing the esophageal sphincter muscle fibers.

After the procedure, the nurse monitors the client for bleed­ing and signs of perforation, such as chest and shoulder pain, elevated temperature, subcutaneous emphysema (air under the skin), or hemoptysis (coughing up blood). The client is taught to expectorate ramer than swallow any secretions that may be produced. The client is also instructed to take nothing by mouth (NPO) for 1 hour and is instructed to limit dietary in­take to liquids for 24 hours. The procedure may be repeated in 2 to 3 months if needed. Most clients report improvement in swallowing.

ESOPHAGOMYOTOMY. Surgical procedures for clients with achalasia are aimed at facilitating the passage of food. Esophagomyotomy, in which the LES is incised, has been used successfully for decades. Both thoracic and abdominal approaches can be used. An antireflux wrap (fundoplication) may or may not be part of the procedure. Esophagomyotomy is a more complex surgical treatment for achalasia. General anesthesia is required, and the client is hospitalized for several days. A thoracotomy approach per­mits exposure of the esophagus. The surgeon cuts muscle fibers around the LES to open the sphincter and thereby pro­vide less obstruction to food passage. For long-term refractory achalasia, the surgeon may at­tempt excision of the affected portion of the esophagus, with or without replacement by a segment of colon or jejunum (partial esophagectomy).

 

Postoperative care for clients undergoing esophagomy­otomy or esophagectomy includes managing chest tubes and drains, assessing healing of the thoracotomy or abdominal in­cision, pain control, and managing nasogastric feedings. (See Chapter 19 for general postoperative care and Chapter 30 for care of the client with a thoracotomy.)

ESOPHAGEAL TUMORS

 OVERVIEW

Tumors occurring in the esophagus can be benign or malig­nant. Benign tumors, usually in the form of leiomyomas, are extremely uncommon and are usually asymptomatic. No spe­cific treatment is required unless they produce symptoms, and then they are generally removed.

Worldwide, esophageal cancer is the third most common gastrointestinal (GI) cancer and the eighth most common can­cer (Parkin, Pisani, & Ferlay, 1999). A relatively uncommon cancer in the United States, it represents about 6% of all can­cers of the GI tract, and mortality from the disease remains very high (Landis et al., 1999).

I Pathophysiology

Most malignant esophageal tumors arise from the epithelium. Fifteen percent of all esophageal cancers are located in the up­per esophagus and are primarily squamous cell in origin. Thirty-five percent of tumors appear in the mid-thoracic region and can be either squamous cell or adenocarcinomas. The lower esoph­agus is the site of approximately 50% of all esophageal cancers, primarily adenocarcinomas. The local and regional lymphatic spread of the disease differs according to the site of the original tumor. It has been proposed that esophageal cancers result from mutations in suppressor genes and proto-oncogenes (see Chap­ter 24 for a more complete discussion).

Esophageal tumors exhibit rapid local growth because there is no serosal layer to limit their extension. Because the esophageal mucosa is richly supplied with lymphatics, there is early spread of tumors to lymph nodes. Esophageal tumors can protrude into the esophageal lumen and either take on a flat­tened and infiltrative form to cause thickening of the lumen or manifest as a necrotic ulceration that invades deeply into sur­rounding tissue. In rare cases the lesion may be confined to the epithelial layer (in situ). In the majority of cases, the tumor is relatively large and well established on diagnosis.

 Etiology

In the United States, the two primary risk factors associated with the development of squamous cell carcinoma of the esophagus are tobacco use and alcohol ingestion. The com­pounds in tobacco smoke may be responsible for the genetic mutations seen in one half of esophageal tumors. A smoker has two to six times the risk of eventually developing esophageal cancer than does a nonsmoker. Some alcoholic beverages contain potent carcinogens that may be responsible for the development of esophageal tumors. Smoking and al­cohol ingestion act synergistically in the development of esophageal cancer.

Long-term exposure to gastric contents, such as that caused by gastroesophageal reflux disease (GERD), also plays a role in esophageal cancer development. Exposure to acid and pepsin leads to the replacement of normal distal squamous mucosa with columnar epithelium as a response to tissue in­jury, causing Barrett’s disease or esophagus. This tissue un­dergoes dysplasia and, ultimately, malignant transformation.

In other parts of the world where esophageal cancer is common, the incidence of squamous cell carcinoma appears to be linked to high levels of nitrosamines (which are found in pickled and fermented foods) and foods high iitrate. Diets that are chronically deficient in fresh fruits and vegetables have been implicated in the development of squamous cell carcinoma.

Certain genetic factors may have a role in the development of esophageal cancer. Overexpression and/or mutations of the p53 tumor suppressor gene have been found in esophageal cancer. In addition, the presence of the p53 gene may be an indication of advanced disease. Tumor cells with a mutated p53 gene have demonstrated resistance to chemotherapy.

Incidence/Prevalence

In the United States, cancer of the esophagus accounts for fewer than 1% of all newly diagnosed cancers and 6% of all tumors involving the gastrointestinal tract. In 1999 there was an estimated 316,000 new cases of esophageal cancer and 286,000 deaths worldwide (Parkin, Pisani, & Ferley, 1999). Although squamous cell cancer accounts for most cases, the rate of adenocarcinoma of the esophagus is also rapidly in­creasing. It is usually found at the gastroesophageal junction and the distal portion of the esophagus. The greatest incidence of adenocarcinoma can be found in Caucasian males of mid­dle to upper socioeconomic status (Quinn & Reedy, 1999).

Esophageal cancer is extremely virulent and has a 5-year survival rate of less than 5%.

 CULTURAL CONSIDERATIONS

 Over the past several decades there have been statisti­cally significant annual increases in the incidence of squa­mous cell cancer of the esophagus in the United States, par­ticularly in African Americans. Mortality rates for esophageal cancer are now second only to those for cancer of the lung.

The incidence of esophageal cancer is extremely high in ar­eas of northwest China, the Caspian Sea (around Russia and Iran), Japan, and the Transkei region of southern Africa. In these groups, the disease is found primarily in the upper to middle esophageal area. Residents of some provinces in China have a 30% to 40% probability of dying from esophageal can­cer. The causes of these extreme variations are being re­searched but have not been satisfactorily explained.

 

COLLABORATIVE MANAGEMENT    

Assessment

 history

The nurse assesses the client’s racial and cultural background, age, sex, and any pertinent history of alcohol consumption, tobacco use, dietary habits, and other esophageal problems (e.g., dysphagia, stricture, or reflux). In collaboration with the dietitian, the nurse also collects a nutrition history, including the ingestion of pickled foods, changes in appetite, changes in taste, or a decline in weight. The degree of weight loss over time is also an important consideration.

Cancer of the esophagus is a silent tumor in its early stages, with few signs to identify on assessment. By the time the tumor causes symptoms, it usually has spread rather extensively.

   PHYSICAL ASSESSMENT/CLINICAL MANIFESTATIONS

The primary clinical manifestations of esophageal cancer are dysphagia (most common) and weight loss (Brooks-Brunn, 2000). The nurse carefully assesses the degree and severity of dysphagia. Tumor-induced dysphagia is both persistent and progressive. It is initially associated with swallowing solids, particularly meat, and then progresses rapidly over a period of weeks or months to difficulty in swallowing soft foods and liq­uids. Late in the disease, even saliva can induce choking. Clients usually report a sensation that food is sticking in the throat or in the substernal area. Careful assessment of the dys­phagia is an important part of the diagnosis because the dys­phagia associated with other esophageal disorders is not usu­ally continuous. Dysphagia does not usually appear until at least 60% of the esophageal diameter is narrowed by the tumor.

 

 

 

 

Odynophagia (painful swallowing) is present in most clients and is reported as a steady, dull, substernal pain that may radi­ate. The presence of severe or persistent pain often indicates tu­mor invasion of the mediastinal structures. The nurse also as­sesses for the occurrence of regurgitation, vomiting, foul breath, and chronic hiccups, which often accompany advanced disease. In most clients, pulmonary complications develop at some point, and the nurse assesses for the presence of chronic cough, increased secretions, and a history of recent infections.

Tumors in the upper esophagus may involve the larynx and thus cause hoarseness. Chart 55-6 summarizes the clinical manifestations of esophageal tumors.

   PSYCHOSOCIAL ASSESSMENT

The symptoms and diagnosis of esophageal cancer can affect a client in profound ways. The disease produces significant daily symptoms, requires major modifications in basic eating patterns, and is terminal. The fear of choking can transform normal mealtimes into frightening experiences that the client may wish to avoid. The nurse carefully assesses the client’s response to the diagnosis and prognosis and explores his or her coping strengths and resources. The impact of the disease on the usual pattern of activities is also assessed. The nurse also assesses the availability of support systems and the po­tential financial impact of the disease and its treatment.

 RADIOGRAPHIC ASSESSMENT

To arrive at a diagnosis of esophageal cancer, the physician first uses a barium swallow study with fluoroscopy. The tu­mor margins of large masses can often be outlined during this test. A definitive diagnosis of cancer necessitates histologic evidence by means of a tissue biopsy.

■ OTHER DIAGNOSTIC ASSESSMENT

The definitive diagnosis of esophageal cancer is made by esophagogastroduodenoscopy (EGD) with biopsies of the esophagus and tumor. The physician performs an endoscopic examination to inspect the esophagus and to obtain specimens for cytologic studies and staging. Multiple tissue samples may be required when the suspected tumor is in the distal esopha­gus, because clear tissue samples are difficult to obtain.

KEY FEATURES of Esophageal Tumors

 

Persistent and progressive dysphagia (most common feature)

Feeling of food sticking in the throat Odynophagia (painful swallowing)

Severe, persistent chest or abdominal pain or discomfort

Regurgitation

Chronic cough with increasing secretions

Hoarseness

Anorexia

Nausea and vomiting

Weight loss (often >20 pounds)

Changes in bowel habits (diarrhea, constipation, bleeding)

 

A complete staging workup is performed to determine the extent of the disease. A computed tomography (CT) scan assists in identifying metastatic disease that can be present in the chest or abdomen. Positron emission tomography (PET) is a newer technology that may identify metastatic disease with more accuracy than a CT scan. Metastasis can also be diag­nosed by bone and brain scans or exploratory laparoscopy. An endoscopic ultrasound (EUS) is a staging technique that can help determine the size and depth of tumor invasion. (These tests are described elsewhere in this text.)

CRITICAL THINKING CHALLENGE

·                          You are gathering the initial history on a 65-year-old fe­male Asian client admitted with dysphagia and a recent weight loss of 20 pounds over 3 months. The client states she used to smoke 2 packs of cigarettes per day for 30 years but quit 15 years ago. The client also admits to a 5-year history of gas­trointestinal reflux, especially after eating in the late evening.

·    What lifestyle and cultural factors place this client at risk for esophageal cancer?

·    What specific questions would you ask concerning her swallowing difficulties?

·    What additional clinical manifestations should you inquire about?

 Analysis

  COMMON NURSING DIAGNOSES AND COLLABORATIVE PROBLEMS

The priority nursing diagnosis for clients with cancer of the esophagus is Imbalanced Nutrition: Less than Body Require­ments related to impaired swallowing.

 ADDITIONAL NURSING DIAGNOSES AND COLLABORATIVE PROBLEMS

In addition to the commoursing diagnosis, the client with esophageal cancer may develop any of the following due to the impact of the disease and/or treatment:

·        Risk for Aspiration related to impaired swallowing sec­ondary to esophageal strictures

·        Impaired Swallowing related to obstruction by the tumor or the effects of radiotherapy

·                          Acute Pain or Chronic Pain related to the pressure of the tumor mass in the esophagus or mediastinum

·        •      Ineffective Coping and Compromised Family Coping re­lated to the effects of the disease and to the terminal prognosis

·                          Anticipatory Grieving related to declining physical sta­tus and terminal prognosis

·        •      Spiritual Distress related to impending death

·                          The additional collaborative problem is Potential for Metas­tasis due to the close proximity of the esophagus to other body structures.

 Planning and Implementation

■  IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS

 

INTERVENTIONS. Interventions to maintain or im­prove the nutritional status of the client must focus on treat­ments to remove or shrink the obstructive tumor and on ame­liorating the effects of treatment that can impact nutritional status.

Treatment options for cancer of the esophagus that can as­sist in both disease and nutrition management include the fol­lowing:

·    Nutritional support
 Radiotherapy

·    Photodynamic therapy

·    Dilation of strictures

·    Prosthesis insertion

·                          Chemotherapy Surgical removal of the tumor

Much has been done over the last decade to try to improve the outcome for clients diagnosed with esophageal cancer. The typical treatment plan uses a combination of the above approaches. The current trend includes chemotherapy with or without surgery in an effort to improve the odds of obtaining a cure. Clients with cancer of the esophagus can experience many problems, and relieving symptoms becomes an essen­tial consideration.

 NUTRITION THERAPY. The purpose of nutrition therapy is the administration of food and fluids to support the meta­bolic processes of a client who is malnourished or at high risk for becoming malnourished. A thorough nutritional assess­ment provides members of the health care team with baseline information concerning the client’s nutritional status. The di­etitian determines the caloric needs of the client to meet nu­tritional requirements. The nurse or assistive nursing person­nel weighs the client daily. Careful positioning is essential for a client who is experiencing frequent regurgitation or who has prosthetic tubes to keep the esophagus patent. The nurse teaches the client to remain upright for several hours after meals and to avoid lying completely flat. The head of the bed is always elevated 30 degrees or more to prevent reflux.

Semisoft foods and thickened liquids are preferred because they are easier to swallow. Caloric intake and the amount of fluids ingested are monitored daily to monitor progress to­ward nutritional goals. In addition, liquid nutritional supple­ments can be used between feedings to increase caloric in­take. Ongoing efforts are made to preserve the ability to swallow, but feeding tubes may be needed temporarily when dysphagia is severe. In clients with complete obstruction or life-threatening fistula formation, it may be necessary to cre­ate a gastrostomy or jejunostomy. The nurse monitors labora­tory and clinical indicators of nutritional status. The client may also benefit from diet teaching and planning.

 SWALLOWING THERAPY. The nurse consults with the speech-language pathologist to assist with oral exercises to improve swallowing. A lollipop given to the client to suck on can enhance tongue strength. The client is instructed to reach for food particles on the lips or chin using the tongue. In preparation for swallowing, the nurse assists the client to po­sition the head in forward flexion (chin tuck). The client is in­structed to place food at the back of the mouth. The nurse monitors for the sealing of lips and for tongue movements while eating and also checks for pocketing of food after swal­lowing. It is important the nurse monitor for signs of aspira­tion. Family members and/or caregivers are taught how to feed the client, monitor for aspiration, and institute appropri­ate measures should choking occur. Chart 55-7 provides a summary of NIC interventions.

NONSURGICAL MANAGEMENT. Treatment decisions are based on the location and size of the tumor, the presence of metastasis, the client’s concurrent health status, and the client’s ability to withstand radical surgery.

The focus of nonsurgical treatment is palliative care. The outcomes of palliative care are the relief of symptoms and improved duration of survival. A combination of chemother­apy, radiation, pain control, and nutritional support measures can be used. The physician selects nonsurgical management when a client is either unable or unwilling to undergo exten­sive surgery.

RADIATION THERAPY. Radiation therapy to manage esophageal cancer is only moderately effective and can be used alone or in combination with other modalities. Used alone, radiation has been effective in the palliation of ad­vanced esophageal cancer, with improvement in symptoms in 50% to 76% of cases (Behrend, 1999). Radiation therapy is contraindicated for clients with tracheoesophageal fistula, mediastinitis, mediastinal hemorrhage, or infiltration of the cancer to the trachea or bronchus (Gregoire & Fitzpatrick, 1998). Radiation reduces tumor size and offers clients consis­tent short-term relief. Although higher doses of radiation demonstrate better results, esophageal stricture or stenosis can result in 30% to 50% of clients requiring esophageal di­lation. Normal esophageal tissue is very sensitive to the ef­fects of radiation. The treatment is typically administered in twenty episodes over 4 weeks.

INTERVENTION ACTIVITIES/or

The Client with Esophageal Problems

Nutrition Therapy: Administration of food and fluids to sup­port metabolic processes of a client who is malnourished or at high risk for becoming malnourished

• Determine—in collaboration with the dietitian, as appro­ priate—number of calories and type of nutrients needed to meet nutrition requirements.

• Assist the client to a sitting position before eating or feeding.

• Encourage the client to select semisoft food, if lack of saliva hinders swallowing.

• Select malts, shakes, and ice cream to supplement nutrition

• Monitor food/fluid ingested and calculate daily caloric in­ take, as appropriate

• Determine need for nasogastric tube feedings Swallowing Therapy: Facilitating swallowing and prevent­ing complications of impaired swallowing

• Collaborate with speech therapist to instruct client/family about swallowing exercise regimen.

• Explain the rationale of the swallowing regimen to client/family.

• Provide a lollipop for client to suck on to enhance tongue strength, if appropriate.

• Assist client to position head in forward flexion in prepa­ration for swallowing (“chin tuck”).

• Assist client to place food at back of mouth and on unaf­fected side.

• Monitor for signs and symptoms of aspiration.

• Instruct family/caregiver how to position, feed, and moni­tor client.

• Instruct client/caregiver on emergency measures for choking.

 

 

In the first weeks of treatment, radiation produces edema and epithelial desquamation, which often create acute esophagitis and odynophagia (painful swallowing). Profound anorexia, nausea, and vomiting may also result. Symptoms persist until treatment is completed. The nurse assesses the client frequently to determine the incidence and severity of symptoms. Systemic analgesics are often required to control discomfort, and the nurse administers topical lidocaine (Vis­cous Xylocaine) before each attempt at oral feeding.

The nurse works with the client to modify the diet to meet nutritional needs and maintain comfort. Small, frequent, soft or semiliquid meals are offered. Sweet, light foods are often tolerated best, and protein powder may be used to supplement the nutritional content of the diet. The nurse maintains accu­rate records of calorie counts, intake and output, and daily weights and also assesses skin turgor and mucous membranes regularly. In collaboration with the physician and dietitian, the nurse assesses the need for enteral nutrition if oral intake is insufficient.

For clients receiving radiation therapy, frequent gentle mouth care is important. Clients are at risk for monilial esophagitis, and the nurse is alert to any abrupt worsening of symptoms. Chapter 25 describes additional nursing interven­tions for the client undergoing radiation therapy.

PHOTODYNAMIC THERAPY. Photodynamic therapy (PDT) was originally used for the treatment of skin cancer. In 1995 it was approved for use as a palliative treatment for indi­viduals with advanced esophageal cancer, who are not candi­dates for surgery. The client is injected with porfimer sodium (Sanofi Pharmaceuticals, New York), a light-sensitive drug that acts to amass cancer cells. Two days after the injection, a fiberoptic probe with a light at the tip is threaded into the esophagus. The light activates the Photofrin, destroying only cancer cells. PDT is far less invasive than surgery and is per­formed on an ambulatory care basis under conscious sedation.

The side effects of Photofrin are rare but include nausea, fever, and constipation. After the procedure, the client is given written guidelines concerning photosensitivity measures. The client is instructed to avoid exposure to sunlight for 1 month. Sunglasses and protective clothing that covers all exposed body areas are essential. The client may experience chest pain secondary to tissue damage and will require pain relief with opioids for a short time. The client is instructed to follow a clear liquid diet for 3 to 5 days after the procedure and ad­vance to full liquids as tolerated (Durkin, 1999).

ESOPHAGEAL DILATION. Esophageal dilation may be performed as necessary throughout the course of the disease to achieve temporary but immediate relief of dysphagia. Esophageal dilation can be performed on an ambulatory care basis. The physician uses dilators to tear soft tissue, widening the esophageal lumen. In most cases, malignant tumors may be dilated safely, but perforation remains a significant risk. Bacteremia can also occur. To reduce the risk of endocarditis, the American Heart Association recommends prophylaxis with antibiotics (Behrend, 1999). The treatment is repeated as often as needed to preserve the client’s ability to swallow (see p. 1204).

PROSTHESIS INSERTION. The physician may insert a semirigid prosthesis to bypass disabling dysphagia and to pre­vent aspiration in clients who have advanced disease or tra-cheoesophageal (TE) or esophagobronchial (EB) fistulas. Prosthesis insertion can maintain an open esophagus and pre­serve the client’s ability to receive oral nourishment and thus palliate the symptoms related to obstruction. The procedure is not without risk, and acute complication rates have been re­ported to occur in 16% to 18% of clients (Raltz & Kozarek, 1999). The prosthesis can become dislodged, migrate, or per­forate the esophagus as tumor bulk increases.

The nurse’s primary care emphasis is the prevention of as­piration. The prosthesis interrupts the function of the lower esophageal sphincter (LES) and permits the free reflux of gas­tric contents. The nurse supervises the client closely, offers small oral feedings, and ensures that the client does not lie flat in bed.

CHEMOTHERAPY. The use of chemotherapy in the treat­ment of esophageal cancer has been only moderately effec­tive. The two chemotherapeutic agents used to treat squamous cell carcinoma are 5-fluorouracil (5-FU) and cisplatin. Cur­rently, there is no standard treatment for adenocarcinoma of the esophagus. Chemotherapy can be given before surgery to decrease tumor size, thereby facilitating surgical resection (Quinn & Reedy, 1999). Chemotherapy appears to be more effective when given in combination with radiation. Cisplatin and 5-FU make the tumor cells more sensitive to the effects of radiation. Chemotherapy can be administered concurrently with radiotherapy before surgery. This treatment is thought to provide the client with the best chance of cure.

 CRITICAL THINKING CHALLENGE

·                          Your client has been diagnosed with esophageal can­cer and is undergoing preoperative radiation for tumor reduc­tion before surgical resection.

·                          What  possible complications related to this treatment should the nurse assess for?

·                          What nursing interventions could be instituted to assist the client in maintaining adequate nutritional intake?

·                          What should the nurse include in the teaching plan for this client?

SURGICAL MANAGEMENT

 Radical surgery represents the only definitive treatment for esophageal cancer and is the preferred treatment for clients with no evidence of advanced disease. The goals of surgical resection vary from palliation to cure. Esophagectomy is an extensive surgical procedure and is associated with significant morbidity and mortality. Mor­tality from the surgical procedure ranges from 10% to 20%. Complications from surgery (e.g., fistula formation, abscess, and respiratory complications) occur in 20% to 50% of indi­viduals (Behrend, 1999; Mayer, 1998).

PREOPERATIVE CARE. Preoperative preparation for clients undergoing esophagectomy or esophagogastrostomy can be quite extensive. Clients are advised to stop smoking 2 to 4 weeks before surgery to enhance their pulmonary func­tioning. Client preparation for surgery may include 5 days to 2 to 3 weeks of nutritional support in an effort to improve their nutritional status and decrease postoperative morbidity. Ideally, this supplementation is given orally, but most clients usually require tube feeding or parenteral nutrition. The role of parenteral nutritional support in these clients remains con­troversial (Sikora et al., 1998). The nurse carefully monitors the client’s weight, intake and output, and fluid and elec­trolyte balance. A preoperative dental evaluation may be re­quired to remove pre-existing dental caries. Meticulous oral care is performed four times daily to decrease the risk of post­operative infection.

Preoperative nursing care also focuses on teaching and on psychologic support. The nurse ensures that the client is knowledgeable about the surgery and its outcomes. The physician’s instructions are clarified and reinforced as needed. The nurse explains the following:

•  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 intravenous (IV) infusion

The client visits the critical care unit, if possible, and initi­ates contacts with unit staff.

The nurse instructs the client about routines for turning, coughing, deep breathing, and chest physiotherapy. The cru­cial nature of postoperative respiratory care is emphasized. The nurse addresses the probable need for ventilator support, because respiratory management is a major focus of postop­erative care. If colon interposition is planned, the client also undergoes a complete bowel preparation with laxatives and enemas before surgery.

The client facing a serious illness and extensive surgery can be expected to display feelings of grief and anxiety. The nurse encourages the client to talk about personal feelings and fears and involves the family or significant others in all pre­operative teaching and discussions. A primary nurse or case manager can be extremely helpful in providing continuity of care and support to the entire family.

OPERATIVE PROCEDURES. A subtotal or total esoph­agectomy is usually required because tumors are often quite large and involve distant lymph nodes. Several procedures have been used, but the preferred surgical procedure is an esophagogastrostomy. The diseased portion of the esopha­gus is removed, and the cervical portion is anastomosed (con­nected) to the stomach. The cervical portion of the stomach is then brought up into the thorax through the esophageal hiatus (Figure 55-5). A vagotomy is also usually performed with this type of resection, resulting in hypertonicity of the pylorus. A pyloromyotomy is created to prevent gastric motility distur­bances. Lastly, a jejunostomy tube is placed for postoperative enteral feeding.

For a client 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 there is no entry into the pleural space, thereby minimizing respiratory com­plications.

For a client with tumors in the upper esophagus, radical neck dissection and laryngectomy may also be required because of the spread of disease 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 (see Figure 55-5).

These surgical procedures pose cardiovascular risks for the client. Intraoperative hypotension can result from pressure on the posterior heart. Decreased lymphatic pulmonary clearance can predispose the client to pulmonary edema when mediasti-nal lymph nodes and lymphatics are resected. The stress placed on the heart by extensive surgery can increase the risk of myocardial ischemia and dysrhythmias, especially if the client has underlying coronary disease.

The client with compromised nutritional status or prior ra­diation or chemotherapy is predisposed to an increased risk of infection. For clients who undergo more radical surgical pro­cedures, there is a serious risk of leakage at the anastomosis site. This situation is especially true with colon interpositions because several anastomosis sites are vulnerable to the effects of tension, poor blood supply, and delayed healing. Medias-tinitis resulting from an anastomotic leak can lead to fatal sepsis.

POSTOPERATIVE CARE. The client requires meticulous postoperative care and is at risk for multiple serious compli­cations. The Client Care Plan on pp. 1199 and 1200 outlines client interventions for esophageal surgery.

Respiratory Care. Respiratory care is the highest post­operative priority, and the client is usually intubated and me­chanically ventilated for at least the first 24 hours. Postopera­tive pulmonary complications include atelectasis and pneumonia. The risk of postoperative pulmonary complica­tions is increased in the client who has received preoperative radiation. Once the client is extubated, the nurse begins deep breathing, turning, and coughing routines. Chest physiother­apy is initiated as ordered, usually every 2 to 4 hours. The nurse assesses the client for decreased breath sounds and shortness of breath every 1 to 2 hours. Incisional support and adequate analgesia are essential for effective coughing and should be administered regularly if the client’s vital signs re­main stable. The nurse keeps the client in a semi-Fowler’s or high Fowler’s position to support ventilation and prevent re­flux. The physician prescribes prophylactic antibiotics and supplemental oxygen; blood gases are ordered regularly. The nurse ensures the patency of the water seal drainage system for chest tubes and monitors for changes in the volume or color of the drainage.

 

Cardiovascular Care. Hypotension can occur secondary to pressure placed on the posterior heart and may respond well to vigorous IV fluid administration. The nurse also mon­itors for signs and symptoms of fluid volume overload, par­ticularly in clients who have undergone lymph node dissec­tion. The nurse assesses for edema, crackles in the lungs, and increased jugular venous pressure. In the immediate postop­erative phase, the client may be 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.

Figure 55-5    •    Surgical approaches to the treatment of esophageal cancer.

Atrial fibrillation is a dysrhythmia that results from irritation of the vagus nerve during surgery. Management of atrial fib­rillation can include digitalization, beta blockers, or car-dioversion. (See Chapter 34 for more information on atrial fibrillation.)

Wound Management. Wound management is another significant postoperative concern because the client typically has multiple incisions and drains. The nurse provides inci-sional support during turning and coughing to prevent dehis-cence. Wound infection usually occurs 4 to 5 days after sur­gery. Postoperative leakage from the site of anastomosis is a dreaded complication that can appear 2 to 10 days after sur­gery. If an anastomic leak occurs, all oral intake is discontin­ued and is not resumed until the leak has healed. Nutrition may be given through the jejunostomy tube during the heal­ing process. The nurse carefully assesses for fever, fluid ac­cumulation, general signs of inflammation, and symptoms of early shock (e.g., tachycardia, tachypnea) and reports these findings to the health care provider immediately.

Nasogastric Tube Management. A nasogastric (NG) tube is placed intraoperatively to decompress the suture line. The nurse monitors the NG tube for patency and carefully se­cures the tube to prevent dislodgment, which can disrupt the sutures at the anastomosis. The nurse does not independently irrigate or reposition the NG tube in clients who have under­gone esophageal surgery. 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 bleeding at the suture line. The nurse pro­vides oral hygiene every 2 to 4 hours while the tube is in place (Chart 55-8).

 

BEST PRACTICE/or

Managing the Client with a Nasogastric Tube

After Esophageal Surgery

Check for tube placement every 4 to 8 hours. Ensure that the tube is patent (open) and draining; drainage should turn from bloody to yellowish green by the end of the first postoperative day. Secure the tube well to prevent dislodgment. Do not irrigate or reposition the tube without a physi­cian’s order.

Provide meticulous oral and nasal hygiene every 2 to 4 hours.

Keep the head of the bed elevated to at least 30 de­grees.

When the client is permitted to have a small amount of water, place the client in an upright position and observe for dysphagia (difficulty swallowing). Observe for leakage from the anastomosis site, as indi­cated by fever, fluid accumulation, and manifestations of early shock (tachycardia, tachypnea, altered mental status).

Nutritional Care. The nutritional management of the client who has undergone an esophageal surgery is an early postoperative concern. On the second postoperative day, ini­tial feedings begin through the jejunostomy tube. The feed­ings are slowly increased over the next several days. Feeding by this method can be discontinued once the client is taking adequate oral nutrition. However, some clients may require jejunostomy feedings for approximately 1 month if small amounts of aspiration are detected.

Before beginning oral feedings, a cine-esophagram study is performed to detect the presence of anastomotic leaks, strictures, or signs of aspiration. If no leaks are detected, an esophageal diet is begun, starting with liquids. If liquids are well tolerated, the client’s diet is advanced to include semi-solid foods and then solid foods. The nurse supervises the client during all initial swallowing efforts and ensures that he or she is in an upright position. The food storage area of the stomach has been radically decreased, and gravity is the client’s only real defense against reflux. The nurse continues to assess for signs of leakage.

The client is instructed to consume 6 to 8 meals per day and to ingest fluids between, rather than with, meals to pre­vent diarrhea. Diarrhea can occur 20 minutes to 2 hours after eating and can be symptomatically managed with loperamide before meals. The diarrhea is thought to be the result of va-gotomy syndrome, which develops as a result of the inter­ruption of vagal fibers to the abdominal viscera during sur­gery. This syndrome is diminished by pyloroplasty.

 CRITICAL THINKING CHALLENGE

·                                           Your client has completed a course of preoperative ra­diation therapy, and has undergone an esophagogastrostomy as part of her esophageal cancer treatment.

·                                           What postoperative complications should you assess for and why?

·                                           What nursing interventions would be most appropriate for preventing postoperative complications?

Community-Based Care

Clients with esophageal cancer have many challenges to face once they are discharged home. The combination treatment regimens cause long-lasting side effects, such as fatigue and weakness. These complex treatments also require the client to be knowledgeable about symptom management and to know when to report issues of concern to the health care provider. (See Chapter 25 for care of the client undergoing radiation therapy and chemotherapy.)

  HOME CARE MANAGEMENT

The care given in the hospital is continued after discharge to the community. Ongoing respiratory care is a priority, and family members are instructed to assist with ambulation, splinting inci­sions, and use of the incentive spirometer. The nurse teaches the family to protect the client from infection and to contact the physician immediately if signs of respiratory infection develop. The client is encouraged to be as active as possible and to avoid excessive bedrest and its complications at all costs.

  HEALTH TEACHING

Wound healing is also an ongoing concern. The nurse teaches the client and family to inspect the incisions daily for redness, tenderness, swelling, odor, and discharge. The client and fam­ily are instructed to report a temperature greater than 101° F (38.3° C).

The nurse prepares written instructions about the signs of anastomosis leakage and the importance of reporting them to the physician or other health care provider immediately. The client and family members are instructed to report the pres­ence of fever and a swollen, painful neck incision, which in­dicates a cervical anastomotic leak (Gregoire & Fitzpatrick, 1998).

Nutritional support also remains a concern. The nurse en­courages the client to continue increasing oral feedings as tol­erated. The client is reminded to eat a high-calorie, high-protein diet that contains soft and easily swallowed foods. Meals should be small and frequent, and nutritionally empty foods are avoided. Eggnogs and milkshakes may be easily prepared and enriched to supplement meals. The client needs to learn what foods can be tolerated and needs to adjust his or her eating pattern to ingest food more slowly than before. In­dividuals who have undergone esophageal resection can lose up to 10% of their body weight. The client is taught to moni­tor his or her weight at home and to report a weight loss of 5 pounds or more. If sufficient oral intake is not possible, the family may need instruction about tube feedings or parenteral nutrition at home. (See the Legal/Ethical Issues in Health Care box above.)

WITHHOLDING FOOD AND FLUIDS

Providing nutrition and hydration by means of IV catheters or gastric intubation raises many issues. Societal norms sur­round the provision of food and fluids to individuals who are deemed vulnerable, and this act is viewed differently than complex medical interventions. In addition, there is concern that withholding food and fluids may cause discomfort or suf­fering. Although there is agreement that ethical principles should be used to guide decision making in the provision or withdrawal of food and fluids, there is evidence to suggest that there are few potential benefits to providing nutrition to those with terminal or protracted illnesses.

Although there are no easy answers to this dilemma, a guide to decision making is suggested. The first consideration should be the previous wishes and evidence of current sensa­tion of the individual involved. Second, the benefits and bur­dens of nutrition and hydratioeed to be evaluated in terms of long- and short-term goals. Finally, the interests of all par­ties involved should be represented. Clinicians should focus on reaching a consensus by incorporating an existing knowl­edge of feeding and hydration with consideration based on the wishes of the individual. The views of all stakeholders, and the given benefits and burdens of each case should also weigh in the decision.

 

The nurse emphasizes the importance of keeping the client upright after meals and elevating the head of the bed on blocks. Families are counseled that dysphagia or odynophagia may recur because of stricture, reflux, or cancer recurrence. These symptoms should be promptly reported to the health care provider.

Despite radical surgery, the client with cancer of the esophagus still has a terminal illness and a relatively short life expectancy. Emphasis is placed on maximizing quality of life. Realistic planning is important as the client’s condition even­tually worsens, and the client and family are assisted to plan for the future together. The nurse assists family members in exploring formal and informal sources of support. When needed, the nurse helps the family or significant others arrange for hospice care.

 HEALTH CARE RESOURCES

The nurse initiates referrals to community or home care or­ganizations to assist the family in providing the needed home care. The client may need transportation to the radiation treat­ment center 5 times per week for up to 6 weeks. Oncology nursing care may be needed to monitor and evaluate the client who is receiving chemotherapy at home through venous ac­cess devices or portable infusion pumps. In addition, the nurse informs the family about the services available through the American Cancer Society. The nurse may also acquaint the family with area hospice services for future planning.

Evaluation: Outcomes

MM The nurse evaluates the care of the client with esophageal cancer on the basis of the identified nursing diagnoses and collaborative problems. The expected outcomes are that the client:

·      Maintains hemodynamic stability free of cardiovascular complications

·      Maintains a patent airway free of respiratory complications Is free of infection

·       Is able to consume adequate nutrition and maintain a sta­ble weight

·      Is able to swallow comfortably

·      States that pain is controlled through pharmacologic and nonpharmacologic pain control measures

·      Successfully adapts to the stresses surrounding the diag­nosis and treatment with meaningful support from fam­ily or significant others

DIVERTICULA

 OVERVIEW

Diverticula are sacs resulting from the herniation of esophageal mucosa and submucosa into surrounding tissue. Clients com­plain of dysphagia, regurgitation, nocturnal cough, and halitosis (bad breath).

Diverticula may develop anywhere along the length of the esophagus. No environmental risk factors are known to be in­volved in the development of esophageal diverticula. The in­complete or late opening of the cricopharyngeal muscle dur­ing swallowing leads to high pressures in the hypopharynx and leads to Zenker’s diverticulum, the most common form. Zenker’s diverticulum occurs most often in older adults. Clients with esophageal diverticula can be at risk for esophageal perforation because the mucosa is without the protection of the normal esophageal muscle layer.

As with other forms of reflux, nocturnal problems associated with diverticula are best managed by sleeping with the head of the bed elevated and avoiding the recumbent position for at least 2 hours after eating. The client is also counseled to avoid vigor­ous exercise after meals. The nurse advises the client to avoid re­strictive clothing and frequent stooping or bending.

Surgical management is aimed at excising the diverticula and reapproximating the mucosa. Most physicians use the cervical surgical approach above the clavicle. Postoperatively, the client takes nothing by mouth for several days to promote healing and receives IV fluids for hydration, tube feedings, and then oral fluid and food. The nurse provides pain relief measures and monitors 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 ordered by the surgeon. This tube may be used later for feeding.

Community-based care includes teaching the client and family about the following:

* Tube feeding and resuming an oral diet

* Positioning guidelines to prevent reflux

* Warning signs of complications

Community resources are usually not needed for uncom­plicated cases.

TRAUMA

OVERVIEW

Trauma to the esophagus can result from blunt injuries, chem­ical burns, surgery or endoscopy, or the stress of protracted severe vomiting (Table 55-2). Trauma may affect the esopha­gus directly, impairing swallowing and nutrition, or it may create problems and complications in related structures such as the lungs or mediastinum. The incidence of most forms of esophageal trauma is low in adults.

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. The oral cavity is also usually damaged, and the damage is rapid and severe. Acid burns tend to affect the superficial layers of the esophagus, whereas alkaline substances cause deeper penetrating injuries.

 

TABLE 55-2      CAUSES OF ESOPHAGEAL PERFORATION

Straining

Seizures

Trauma

Foreign objects

Instruments or tubes

Chemical injury

Complications of esophageal surgery

Ulcers

 

COLLABORATIVE MANAGEMENT

The diagnosis of esophageal diverticula is made by x-ray ex­amination and barium swallow. Endoscopy must be per­formed with strict care in these clients, because perforation can occur.

Diet therapy and positioning are the major interventions for controlling symptoms related to diverticula. The dietitian asagement. When caustic burns involve the oral cavity, topical agents, such as 50/50 diphenhydramine hydrochloride (Ben-adryl) and kaolin with pectin (Ka-Pectolin) or topical lido-caine (Viscous Xylocaine), may be used for topical analgesia and local anti-inflammatory action.

If nonsurgical management is not effective in healing trau­matized esophageal tissue, the client may need surgery to re­move the damaged tissue. The client with severe injuries may require resection of part of the esophagus with a gastric pull-through and repositioning or replacement by a bowel segment. (See Surgical Management [Esophageal Tumors], pp. 1208 and 1209.)