Management of Oral and Esophageal Disorders

Common Problems Associated with Gastrointestinal Tract

Ulceration Obstruction Tumors Alterations in secretory function Perforation and hemorrhage

Common Diagnostic Tests Associated with the Gastrointestinal Tract

CBC Clotting factors Serum electrolytes Serum enzyme assays Tumor markers Urine tests Stool tests Diagnostic xrays CT Endoscopies Gastric analysis Ultrasound Nuclear scans

Oral Disorders
What is the most important implication of changes in the oral cavity? What is the most important management strategy? Review Table 35-1: Disorders of the Lips, Mouth and Gums, p. 1143-1144 Review dental, jaw, and salivary gland disorders in the text.

Cancer of the Oral Cavity

Curable if detected early Often associated with alcohol and tobacco use Malignancies are usually squamous cell cancers Any area can be affected Few or no symptoms early Later: most frequent symptom is painless sore or mass that will not heal

Cancer of the Oral Cavity:

Assessment and Diagnostics Oral exam Assessment of cervical lymph nodes Biopsies Medical Management Variable Surgical resection Radiation Chemotherapy Neck dissection often necessary

Oral Cancer: Nursing Management

Pre- and Post-operative teaching Assessment and management of nutritional status Monitoring patency or radial graft is used Monitoring and maintaining patent airway post-operatively Suction carefully as not to disrupt graft

Neck Dissection
Radical Modified Radical Selective Reconstruction techniques performed with a variety of grafts

Neck Dissection: Nursing Management

Pre-operative education General post-operative care Airway maintenance Pain relief Wound care Adequate nutrition Supporting coping measures Promoting effective communication Maintaining physical mobility Monitoring and managing potential complications
Hemorrhage Chyle fistula Nerve injury

Hiatal Hernia
Protrusion of stomach through esophageal hiatus into the thorax Two types:
Sliding (type I) Paraesophageal (type II IV)

Many asymptomatic Symptoms:

Type I: heartburn, regurgitation, dysphagia Type II: fullness or chest pain after eating

Hiatal Hernia
Assessment and Diagnostics Xray studies Barium swallow Fluoroscopy Management Frequent small meals Do not recline for 1 hour after eating Elevate HOB 4 8 inches Surgery indicated in about 15%

Esophageal Diverticulum
Outpouching of the mucosa and submucosa Most common: Pharyngoesphageal pulsion (Zenker s diverticulum)
Symptoms: dysphagia, fullness in the neck, belching, regurgitation, gurgling noise after eating, halitosis and sour taste Diagnostics: barium swallow, esophagoscopy Management: surgical removal of diverticulum

GERD
Backward flow of GI contents Reflex esophagitis Pathophysiology:
Incompetent lower esophageal sphincter (LES) Irritation due to refluxate Delayed gastric emptying

GERD
Clinical Manifestations Pyrosis Dyspepsia Regurgitation Hypersalivation Dysphagia/odynophagia Chest pain Belching Flatulence Bloating after eating Assessment and Diagnostics Endoscopy Barium swallow Esophageal pH monitoring Bilirubin monitoring

GERD Management
Avoid situations that decrease LES pressure or cause esophageal irritation Diet therapy Do not eat or drink 2 hours before bed Maintain body weight Avoid tight fitting clothes Elevate HOB 6 8 inches If persistent therapy add pharmacotherapy If continued problem: surgical referral

Barrett s Esophagus
Mucosal lining is altered Precancerous cells develop and initiate healing Clinically manifests with symptoms of GERD Identified by EGD and Biopsy High grade lesions: prophylactic transhiatal esophagectomy Poor surgical risk: photodynamic therapy

Cancer of the Esophagus

Two cell types:
adenocarcinoma squamous cell carcinoma

Primarily distal esophagus and gastroesophageal junction Tumor cells can spread by way of lymphatics

Cancer of the Esophagus

Manifestations dysphagia sensation of a mass in the throat Odynophagia substernal pain or fullness, regurgitation of undigested food foul breath hiccups Assessment and Diagnostics EGD with biopsy and brushing CT of chest and abdomen PET scan Endoscopic ultrasound Exploratory laparoscopy

Esophageal Cancer: Medical Management

Early detection: cure Modalities:
Surgery Chemotherapy Radiation

Late detection: palliation Modalities:

Dilation of the esophagus Laser therapy Endoprosthesis Chemotherapy Radiation

Esophageal Cancer: Nursing Management

Improving nutritional intake Pre- and Post-op teaching ICU post-operatively Low Fowler s progressing to Fowler s position Monitor for regurgitation and prevent aspiration Vigorous pulmonary plan of care NO CHEST PHYSIOTHERAPY DO NOT MANIPULATE NG Barium swallow before oral intake Progressive feedings Remain upright for 2 hrs after eating Drugs:
Antacids, metoclopramide