Unit I Topic

Disorders Of Mouth
And Esophagus

Riaz Gul (Senior Nursing

Instructor)

BSN,MSN
(AGA Khan University)
 Objectives
• By the end of the session learners will be able to:
1. Review the anatomy and physiology of gastro intestinal
system(GIT).
2. Discuss the causes, pathophysiology and manifestations
of the following GIT disorders.
3. Discuss the diagnostic, medical and surgical
management of the disorders.
4. Apply nursing process including assessment, planning,
implementation and evaluation of care provided to the
client with GIT disorders.
5. Develop a teaching plan for a client experiencing
disorder of the GIT.
 Disorders Of Mouth And Esophagus
• There are many disorders of mouth and esophagus, some
are:
1. Stomatitis
2. Oral cancer/tumor
3. Salivary gland disorders
4. Gastro esophageal reflux disorder
5. Hiatal hernia
6. Achalasia
7. Diverticula
8. Esophageal cancer/tumor
STOMATITIS
1. Stomatitis
• Stomatitis is inflammation of the mouth and
lips.
• It refers to any inflammatory process affecting
the mucous membranes of the mouth and
lips.
• Mucous membranes are the thin skin covering
on the surface of mouth and it produces
protective mucus.
 Types of Stomatitis
• The two main types of stomatitis are:
1) Cold Sore: it is also called fever blisters, they
are fluid-filled sores that occur around the
lips. Cold sore usually associated with
tingling, tenderness, or burning before the
actual sores appear.
 Types of stomatitis
2. canker sore: also known as an aphthous
ulcer, is a single pale or yellow ulcer with a
red outer ring or a cluster of such ulcers in
the mouth, usually on the cheeks, tongue, or
inside the lip.
 Causes of Stomatitis
1. Trauma
2. Medications
3. Poor dental hygiene
4. Dehydration
5. Smoking
6. Loose fitting of dental prosthetics
7. Infection( viral, fungal, bacterial)
8. Nutritional deficiency (iron, vitamin B12, B2, B6)
 Pathophysiology
Any injury ,infection, allergy occurs

Invasion of pathogens in the lining of lips or mouth

mucus membranes

Causes growth of pathogenic microorganism

Leads to redness and inflammation

stomatitis
 Manifestation of stomatitis
• Mouth ulcers with a white or yellow layer and red base,
usually inside the lips, cheek, or on the tongue.
• Red Patches.
• Blisters.
• Swelling.
• Main and discomfort in the mouth.
• Fever some times(101-104 degree F)
• Irritability and restlessness.
• Foul smelling breath.
• Lesions that heal in 4-14 days.
 Medical management of stomatitis

1. Water soluble lubricant form mouth and lips.

2. Topical analgesia.
3. Topical anesthesia.
4. Oral pain killers.
5. Antiseptic mouth wash.
 Nursing intervention of stomatitis
1) Give frequent gentle mouth care to the patient.
2) Provide soft brushes.
3) Advise patient to avoid dry, bulky, irritating food and
fluids as well as tobacco and alcohol.
4) Encourage patient to increase fluid intake.
5) Encourage patient to maintain dental hygiene.
6) Administer pain reliving medications as ordered by
doctor.
7) Give cool, non acidic drinks such as water, milk shakes
and apple juice to the patient.
 Nursing intervention of stomatitis
8) Encourage use of straw to make swallowing easy.
9) Provide high protein and vitamins containing diet
to promote healing of the tissues.
10)Encourage patient to suck or chew on vitamin C
supplements or candy to stimulates gum
salivation.
11)Encourage fluid intake of at least 2500ml/day.
12)Apply topical anesthesia over the lesion 15 to
20minutes before meals.
ORAL CANCER
2. Oral Cancer/Tumor
• Oral cancer, also known as mouth cancer,
is cancer of the lining of the lips, mouth, or
upper throat.
• In the mouth, it most commonly starts as a
painless white patch, that thickens, develops
red patches, an ulcer, and continues to grow.
 Types of oral cancer

• Floor of Mouth Cancer.

• Gum Cancer.

• Hard Palate Cancer.
 Types of oral cancer…..

• Inner Cheek Cancer 
(Buccal Mucosa Cancer)

• Lip Cancer.

• Tongue Cancer.
 Causes Of Oral Cancer
1. Tobacco user including: cigarettes, cigar,
pipes, chewing tobacco etc.
2. Alcohol
3. A weak immune system.
4. Family history of cancer.
5. Human papilloma virus (HPV)
 Pathophysiology
Normal lining of the oral mucosa

If any causative agent came in contact

Low-grade dysplasia(the abnormal growth or development

of a tissue or organ).

High-grade dysplasia

Oral cancer
 Manifestations Of Oral Cancer
1. A lip or mouth sore that doesn't heal.
2. A white or reddish patch inside your mouth.
3. Loose teeth.
4. A extra growth in inside mouth.
5. Mouth pain.
6. Difficulty and painful swallowing
7. Ear pain
 Medical Management Of Oral Cancer

1. Chemotherapy
2. Radiation therapy
3. Combination of drugs example(analgesics,
antacids, antiemetic etc.)
 Surgical Intervention Of Oral Cancer

1. Tumor resection
 Nursing Intervention Of Oral Cancer

1. Check vital signs and O2 saturation.

2. Administer medications as order by doctor.
3. Monitor intravenous fluids because patient is
unable to swallow form mouth.
4. Maintain airborne isolation room.
5. Provide emotional support to the patient.
6. Maintain and clear airway.
7. Provide soft or liquid diet to the patient, to avoid
mouth irritation.
 SALIVARY
GLAND DISORDER
3. Salivary Gland Disorder
• Salivary glands are the glands that produce
saliva in your mouth through a system of duct.
• Humans have three paired major salivary
glands (parotid, submandibular, and
sublingual) as well as hundreds of
minor salivary glands.
Salivary Gland
 Types Of Salivary Gland
1. Parotid glands produce a serous, watery
secretion.

2. Submaxillary (Mandibular) glands produce a

mixed serous and mucous secretion.

3. Sublingual glands secrete a saliva that is

predominantly mucous in character.
 Causes of salivary gland disorder
1. Dry mouth
2. poor oral hygiene
3. Dehydration
4. Kinks of salivary duct
5. Tumor
 Manifestation of salivary gland disorder
1. Pain
2. Skin Redness
3. Gradual Swelling Around The Area
4. Tenderness
5. Pus In The Mouth
6. A Terrible taste in the mouth that does not go away.
7. Trouble or pain opening the mouth, chewing, or
swallowing
8. Fever, Chills
9. do not get any better with primary care, such as
hydration and good oral hygiene
 Medical management of salivary gland

• Antibiotics
• Antiviral
• Oral Hydration
• lemon drops or vitamin C lozenges.
 Surgical management of salivary gland
disorder

• superficial or complete parotidectomy.

• Resection of tumor
• Clearance of blockage in salivary duct.
 Nursing intervention for salivary gland
disorder

1. Give medication to stimulate more saliva

secretion.
2. Give sugarless gums and candy's to stimulate
salivation.
3. Avoiding medications that makes dry mouth.
4. Provide analgesic to relive pain.
5. Administer tube feeding.
6. Give antipyretic to relive fever.
7. Maintain good oral hygiene.
8. Increase fluid intake .
GASTROESOPHAGEAL
REFLUX DISORDER
 4.Gastro Esophageal Reflex Disorder
• Gastro esophageal reflux disease (GERD), also
known as acid reflux, is a long-term condition
in which stomach contents rise up into the
esophagus.
• It is a digestive disorder that occurs when
acidic stomach juices, or food and fluids back
up from the stomach into the esophagus.
 Causes Of Gastro Esophageal Reflex Disorder

1. Obesity
2. Bulging of the top of the stomach up into the diaphragm
(hiatal hernia)
3. Pregnancy
4. Connective tissue disorders
5. Delayed stomach emptying.
6. Smoking
7. Eating large meals or eating late at night
8. Eating certain foods (triggers) such as fatty or fried foods.
9. Drinking certain beverages, such as alcohol or coffee
10.Taking certain medications, such as aspirin
 Pathophysiology
lower esophageal sphincter get disturbed due to
causative agent

So then stomach acid flows back

To the Esophagus

Cause heartburn and gastro esophageal reflux

diseases
 Manifestations Of GERD
1. A burning sensation in your chest (heartburn)
2. Chest pain
3. Difficulty swallowing
4. Regurgitation of food or sour liquid
5. Sensation of a lump in your throat
6. If you have nighttime acid reflux, you might also
experience:
7. Chronic cough
8. Laryngitis
9. New or worsening asthma
10.Disrupted sleep
 Medical Management Of GERD
1. Life style modification
2. Control the gastric acid secretion through
medications example: antacids.
3. Diet
 Surgical Management Of GERD
• Laparoscopic antireflux surgery (also called
Nissen fundoplication) is used in the treatment
of GERD when medicines are not successful.
• Surgery involves a procedure called a
fundoplication. The goal of a fundoplication is
to reinforce the lower esophageal sphincter
(LES) to recreate the barrier that
stops reflux from occurring.
 Nursing Intervention Of GERD
1. Strict input and output charting.
2. Maintain hydration.
3. Encourage small frequent meals of high
calories and high protein foods.
4. Small and frequent meals are easier to digest.
5. Instruct to remain in upright position at least
2 hours after meals.
6. Avoid eating at least 3 hours before bedtime.
7. Reinforce lifestyle modification.
Cont.…
8. Administer antacids as ordered by doctor.
9. Teach to avoid alcohol, tea, coffee and
chocolates.
10.Keep patient in upright position to prevent
form reflex.
11.Provide emotional support to the patient.
 Nursing Diagnosis Of GERD
• Impaired nutrition less then body
requirement.
• Acute pain related to irritation of the
esophagus.
• Risk of aspiration related to reflux of gastric
content.
• Pain related to surgery.
HIATAL HERNIA
 5. Hiatal Hernia
A hiatal hernia is a condition in which the upper
part of your stomach bulges through an opening in
your diaphragm.
• Your diaphragm is the thin muscle that separates
your chest from your abdomen.
• A hiatal hernia occurs when part of the stomach
moves upwards into the chest.
 Types Of Hiatal Hernia
• There are two main types of hiatal hernias:
1. sliding hiatal hernia.
2. Paraesophageal hiatal hernia(next to the
esophagus).
 Types Of Hiatal Hernia
• Sliding Hiatal Hernia: The stomach and the
section of the esophagus that joins the
stomach slide up into the chest through the
hiatus. 

• Paraesophageal Hiatal Hernia: part of the

stomach passes or bulges into the chest
beside the esophagus.
 Causes Of Hiatal Hernia
1. Age related changes in diaphragm
2. Injury to the area example any trauma or
surgery occurs.
3. Congenital abnormality
4. Excessive cough, vomiting
5. Straining during bowel movement
6. Exercising or lifting heavy objects
7. obesity
 Pathophysiology
Contributing factors: weight lifting, strenuous activity,
constipation, pregnancy.

Esophageal gastric junction displacement

Decreases lower esophageal pressure

Large opening of esophageal hiatus

Stomach herniates through the hiatus into the chest

heartburn and chest pain occurs

(Hiatal hernia)
 Manifestations Of Hiatal
Hernia
1. Heart burn that gets worse when you lie
down.
2. Chest pain or epigastric pain
3. Trouble in swallowing
4. Belching (burping or releases the air to
reduce the distention)
 Medical Management Of Hiatal Hernia

1. Life style modification

2. Weight loss
3. Administer antacids
4. No meals at least 3 hours prior to sleep
5. Maintain proper dietary habit.
 Surgical Management Of Hiatal Hernia

• Nissen fundoplication: is the

most commonly
performed surgery for a hiatal
hernia. This procedure uses
laparoscopic repair or
keyhole surgery.
• This surgery is minimally
invasive and only requires
the surgeon to make a few tiny
incisions in the abdomen.
 Nursing Interventions Of Hiatal Hernia

1. Given frequent, small feeding /meals that can

passes easily through esophagus.
2. Maintain patient position by keeping head
elevated.
3. Provide oxygen support if needed.
4. Maintain fluid balance and input/ output charting.
5. Modify dietary habits.
6. Avoid eating meals at least 3 hours before bed
time.
 Nursing Interventions Of Hiatal Hernia

7. Sit up right position for 1 to 2hours after

taking meal.
8. Encourage to weight loss.
9. Administer antacids as order by doctor.
10.Provide high fiber diet.
11.Provide hernia support abdominal belt as
ordered by doctor.
12.Promoting regular exercise.
 Nursing Diagnosis Of Hiatal Hernia

• Acute pain related to swelling and pressure.

• Impaired nutritional status related to less then
body requirement.
• High risk for infection related to invasive
procedure.
• Risk of aspiration related to impaired
swallowing.
• Knowledge deficit.
ACHALASIA
 6. Achalasia
• Achalasia is a serious and rare disorder of
esophagus that makes it difficult for food and
liquid to pass into your stomach.
• Achalasia occurs when nerves in the tube
connecting your mouth and stomach (esophagus)
become damaged.
• As a result, the esophagus loses the ability to
squeeze food down, and the muscular valve
between the esophagus and stomach (lower
esophageal sphincter) doesn't work properly.
Types Of Achalasia
 Causes Of Achalasia
1. Hereditary
2. Autoimmune Condition (your body’s immune
system mistakenly attacks healthy cells in
your body).
3. Esophageal cancer
4. Infectious diseases
 Pathophysiology
Genetics

Autoimmunity viral infection

Autoantibodies

Inflammation

Destruction of nerve cells

Achalasia
 Manifestations Of Achalasia
1. Pain and discomfort in your chest.
2. Weight loss
3. Heart burn
4. Intense pain and discomfort after eating.
5. difficulty in swallowing (dysphagia)
6. Regurgitation of Food And Liquids.
 Medical management of Achalasia
1. Oral medications that help to relax the lower
esophageal sphincter include groups of drugs
called nitrates, calcium channel blockers.
2. Stretching of the lower esophageal sphincter
(dilation) example: balloon inflation
3. The injection of botulinum toxin (Botox) into the
sphincter.
 Surgical Management Of Achalasia
• Esophagomyotomy, involves cutting the
esophageal sphincter muscle.(laparoscopic
myotomy)
 Nursing Interventions Of Achalasia
1. Eating Slowly, taking small bites.
2. Avoiding swallowing large volumes of food or
liquid.
3. Maintain fluid balance.
4. Provide pain relive medications as order by doctor.
5. Provide antacids as order by doctor.
6. Provide emotional support.
7. Modification of lifestyle and diet.
DIVERTICULAR
DISEASES
 7. Diverticula
• Diverticular disease consists of inner layer of your
intestine pushes through weak spots in the outer lining.
This pressure makes them bulge out, making little
pouches.
• It involve the development of small sacs or pockets in
the wall of the colon, including three conditions of colon:
1. Diverticulosis
2. diverticular bleeding
3. diverticulitis.
 1.Diverticulosis
• Diverticulosis is the formation of numerous tiny
pockets or diverticula, in the lining of intestines.
• Diverticula, which can range from pea-size to
much larger, are formed by increased pressure
on weakened spots of the intestinal walls by
gas, waste, or liquid.
• Diverticula can form while straining during
a bowel movement, such as with constipation.
They are most common in the lower portion of
the large intestine (called the sigmoid colon).
 2. Diverticular bleeding
• Diverticular bleeding occurs with chronic
injury to the small blood vessels that are next
to the diverticula.
 3.Diverticulitis
• Diverticulitis occurs when there
is inflammation and infection in one or more
diverticula. This usually happens when out
pouching's become blocked with waste, allowing
bacteria to build up, causing infection.
 Causes Of Diverticular Diseases
1. Aging
2. Obesity
3. Smoking
4. Lack of exercise
5. Diet high in animal fat
6. low fiber diet
7. Constipation
8. Pressure or strain on colon
9. Certain medications Several drugs are associated with an
increased risk of diverticular diseases including steroids,
opioids etc.
 Pathophysiology
Low fiber diet

Chronic constipation

Increase intraluminal pressure

Muscular hypertrophy

Herniation of mucosa through the muscular wall

Occurs diverticula's
 Manifestation Of Diverticular Diseases

1. Pain, which may be constant and persist for several

days. The lower left side of the abdomen is the
usual site of the pain.
2. Nausea and vomiting.
3. Fever.
4. Abdominal tenderness.
5. Constipation
6. frequent urination
7. painful urination
8. bleeding from the rectum
 Medical Management Of Diverticular
Diseases

1. Radiographic and hematologic confirmation

of inflammation with in the colon.
2. Treated initially with the antibiotics, laxatives,
antacids.
3. Provide bowel rest.
4. Limit diet until pain resolves.
5. Dietary modification.
 Surgical Management Of Diverticular
Diseases

• Definitive surgery involve resection of the

affected colon with or without anastomosis.
• The sigmoid colectomy with end colostomy.
 Nursing Intervention Of Diverticular Diseases

1) Reinforce patient education regarding dietary modification.

2) Increases fiber in the diet including: grain, fruits, vegetables
and fibers.
3) Increases patient fluid intake.
4) Maintain input and out put charting.
5) Check vital signs including pain .
6) Observe stool for color and consistency.
7) Observe urinary pattern.
8) If surgery become necessary, observe routine preoperative
and post operative nursing care procedure.
9) Provide colostomy care after procedure.
 Nursing Interventions Of Diverticular
Diseases
10)Administer analgesics, antacids and laxatives as order
by doctor.
11)Provide emotional support to patient.
12)Provide perianal care or hygiene care to the patient.
13)Empty bedpans immediately.
14)Monitor patient for other complications including:
imbalance, obstruction, abscess etc.
15)regular exercises promote normal bowel function and
reduces pressure inside your colon, Try to exercise at
least 30 minutes.
 Nursing Diagnosis Related Diverticular
Diseases

• Diarrhea related to inflamed intestinal mucosa

• Altered nutrition that is less then body
requirement related to diarrhea
• Pain related to inflamed bowel
• High risk of infection related to collection of
fecal in diverticula
ESOPHAGEAL
CANCER/
TUMOR
 8. Esophageal Cancer/Tumor
• Esophageal
cancer (esophageal
carcinoma) usually
begins in the cells that
line inside of
the esophagus.
• cancer arising from
the esophagus that
runs between the
throat till the stomach.
 Types Of Esophageal Cancer
• There are two main types of esophageal
cancer.
1. Squamous cell carcinoma
2. Adenocarcinoma
 Type 1. Squamous Cell Carcinoma
• Most common form of esophageal cancer is
squamous cell carcinoma. It begins when
squamous cells (thin, flat cells lining the inside
of the esophagus) begin to grow
uncontrollably.
• Squamous cell carcinoma of the esophagus is
strongly linked with smoking and drinking too
much alcohol.
 Type 2. Adenocarcinoma
• Cancers that start in gland cells are
called adenocarcinomas. This type of cancer is
the most common esophageal cancer. It
usually occurs closer to the stomach.
• Chronic acid reflux, gastro esophageal reflux
disease (GERD), Barrett’s esophagus and
chronic heartburn can increase your risk of
adenocarcinoma esophageal cancer. 
 Pathophysiology

Normal lining of the esophagus

If esophagitis, GERD, Barrett's esophagus

Low-grade dysplasia(the abnormal growth or development

of a tissue or organ).

High-grade dysplasia

Esophageal carcinoma
 Causes Of Esophageal Cancer
1. Smoking
2. Excessive use of alcohol
3. Gastric esophageal reflux disease
4. Barrett's esophagus (which is linked to
chronic heartburn, can turn into cancer of
the esophagus).
5. Obesity
 Manifestation Of Esophageal Cancer

• Difficulty or pain when swallowing

• Weight loss
• Pain in the chest, behind the breastbone
• Coughing
• Hoarseness
• Indigestion and heartburn
• Frequent choking of food
 Medical Management Of Esophageal Cancer
1. There are several tests to determine the stage of
esophageal cancer, including: Chest X-ray, CT scan,
Endoscopy, blood test etc.
2. If cancer is found on early stage it can be treated
with chemotherapy and radiation.
3. If cancer reaches to the last stage patient require
palliative care.
4. Dietary modification

5. Medication to relive the symptoms example

analgesics, antacids, antiemetic's etc.
 Stages Of Esophageal Cancer
• Stage 0 . Abnormal cells (not yet cancer) are found only in the layer of
cells that line the esophagus.
• Stage I . Cancer cells are found only in the layer of cells that line the
esophagus.
• Stage II . The cancer has reached the muscle layer or the outer wall of
the esophagus. In addition, the cancer may have spread to 1 to 2
nearby lymph nodes (small glands that are part of the immune
system).
• Stage III . The cancer has reached deeper into the inner muscle layer
or the connective tissue wall. It may have spread beyond the
esophagus into surrounding organ and/or has spread to more lymph
nodes near the esophagus.
• Stage IV . This is the most advanced stage. The cancer has spread to
other organs in the body and/or to lymph nodes far from the
esophagus.
 Surgical Management Of Esophageal Cancer

1. Part of the esophagus

may be removed in an
operation called
an esophagectomy.

2. Esophageal sent.
 Nursing Interventions Of Esophageal Cancer

1) Focus on the nutritional needs of the patient.

2) Provide care to the client with feeding tube.
3) Provide patient education.
4) Provide emotional support to the patient.
5) Monitor fluid balance.
6) Administer medications to relive symptoms
as order by doctor.
7) Prepare patient for the surgery and provide
post-operative care.
 Nursing Intervention Of Esophageal Cancer

8) Observe oral secretion or saliva for any

bleeding.
9) Provide family education also about diseases
process.
10)Monitor patient weight strictly.
 Nursing Diagnosis Related Esophageal
Cancer
• Imbalance nutrition less then body requirement,
related to nausea and vomiting
• Pain related to mass or tumor
• Risk of deficient fluid volume related to vomiting
and dehydration
• Anxiety related surgery
• Impaired skin integrity related surgical procedure
• Risk of ineffective airway clearance related
secretion
 References
• Brunner, L. S., & Suddarth, D. S. (2005). Text
Book of Medical- Surgical Nursing (10th
Edition). Philadelphia: Lippincott.