(GERD) GASTROESOPHAGEAL REFLUX DISEASE - NURSECE4LESS ...
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Gastroesophageal
Reflux Disease
(GERD)
In The Adult
Elizabeth Boldon, RN, MSN
Elizabeth Boldon is a Nurse Education
Specialist at Mayo Clinic in Rochester,
Minnesota. She received a BSN from Allen College in Waterloo, Iowa in 2002 and an
MSN with a focus in education from the University of Phoenix in 2008. She has
bedside nursing experience in medical neurology and the neuroscience ICU.
Abstract
Gastroesophageal reflux disease (GERD) is defined as a condition that
develops when the reflux of stomach contents causes troublesome
symptoms with or without mucosal damage and/or complications. GERD
symptoms can include nausea, dysphagia, burning chest or abdominal pain,
respiratory disorders and mild to severe damage to the esophageal lining
and functioning. Patients that are not investigated for symptoms or not
followed up through recommended diagnostic testing when damage to the
esophagus has occurred are at risk of further injury and complications,
including Barrett’s esophagus (a precancerous condition). The diagnosis,
symptoms, complications and standard medical and surgical treatment of
GERD are discussed.
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2 Continuing Nursing Education Course Planners William A. Cook, PhD, Director, Douglas Lawrence, MA, Webmaster, Susan DePasquale, MSN, FPMHNP-BC, Lead Nurse Planner Policy Statement This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities. Continuing Education Credit Designation This educational activity is credited for 2 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity. Statement of Learning Need Nurses need to recognize and stay informed of symptoms of gastroesophageal reflux disease (GERD) in the adult, including the current and evolving trends in GERD diagnosis and treatment management. Course Purpose To provide nursing professionals with knowledge to care for adult patients with GERD and to help support improved quality of life. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com
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Target Audience
Advanced Practice Registered Nurses and Registered Nurses
(Interdisciplinary Health Team Members, including Vocational Nurses and
Medical Assistants may obtain a Certificate of Completion)
Course Author & Planning Team Conflict of Interest Disclosures
Elizabeth Boldon, RN, MSN, William S. Cook, PhD, Douglas Lawrence, MA,
Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures
Acknowledgement of Commercial Support
There is no commercial support for this course.
Activity Review Information
Reviewed by Susan DePasquale, MSN, FPMHNP-BC
Release Date: 1/1/2016 Termination Date: 10/27/2018
Please take time to complete a self-assessment of knowledge, on
page 4, sample questions before reading the article.
Opportunity to complete a self-assessment of knowledge learned
will be provided at the end of the course.
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1. GERD affects up to _________ adults in the United States on a daily
basis.
a. 3.5 million
b.5 million
c. 6.8 million
d. 10 million
2. The esophagus is a tube-like structure that is approximately _____
inches long and one _____ inch wide in adults.
a. 15 (inches long) and 2 (inch wide)
b. 13 (inches long) and 3 (inch wide)
c. 10 (inches long) and 1 (inch wide)
d. none of the above
3. Barrett's esophagus is associated with an increased risk of:
a. acid reflux
b. aspiration pneumonia
c. high incidence of malignancy
d. esophageal cancer
4. H-2-receptor blockers do not act as quickly as antacids do, but provide
longer relief and may decrease acid production up to ______ hours.
a. 6
b. 24
c. 8
d. 12
5. PPIs have been associated with slight increase in risk of bone fracture
and vitamin B-12 deficiency.
a. True
b. False
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Introduction
Gastroesophageal reflux disease, or GERD, is a digestive disorder that
affects the lower esophageal sphincter (LES), the ring of muscle between the
esophagus and stomach. Up to 10 million adults in the United States are
affected by GERD on a daily basis.1 GERD has been defined by experts within
international gastroenterology symposiums of the Rome Foundation, such as
Rome III, as a condition that develops when gastric contents reflux into the
esophagus leading to troublesome symptoms with or without damage to the
esophageal mucosa and/or complication.2
Many people, including pregnant women, suffer from heartburn or acid
indigestion caused by GERD. In most cases, GERD can be relieved through
diet and lifestyle changes; however, some people may require medication or
surgery.
Pathophysiology Of GERD
When food is consumed it is carried from the mouth to the stomach through
the esophagus, a tube-like structure that is approximately 10 inches long
and one inch wide in adults. The esophagus is made of tissue and muscle
layers that expand and contract to propel food to the stomach through a
series of wave-like movements called peristalsis.
At the lower end of the esophagus, where it joins the stomach, there is a
circular ring of muscle called the lower esophageal sphincter (LES). After
swallowing, the LES relaxes to allow food to enter the stomach and then
contracts to prevent the back up of food and acid into the esophagus.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com6 However, sometimes the LES is weak or becomes relaxed because the stomach is distended, allowing liquids in the stomach to wash back into the esophagus. This happens occasionally in all individuals. Most of these episodes occur shortly after meals, are brief, and do not cause symptoms. Normally, acid reflux should occur only rarely during sleep. Acid reflux becomes gastroesophageal reflux disease when it causes bothersome symptoms or injury to the esophagus. The amount of acid reflux required to cause GERD varies. In general, damage to the esophagus is more likely to occur when acid refluxes frequently, the reflux is very acidic, or the esophagus is unable to clear away the acid quickly. The most common symptoms associated with acid reflux are heartburn, regurgitation, chest pain, and trouble swallowing (dysphagia). The treatments of GERD are designed to prevent one or all of these symptoms from occurring.3 Both acid reflux and heartburn are common digestive conditions that many people experience from time to time. When these signs and symptoms occur at least twice each week or interfere with daily life, or when a health care provider can see damage to the esophagus, a diagnosis of GERD may be given. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com
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Most people can manage the discomfort of GERD with lifestyle changes and
over-the-counter medications. But some people with GERD may need
stronger medications, or even surgery, to reduce symptoms.4 The symptoms
of GERD are discussed below, including those factors that trigger and
potentially alleviate symptoms.
Symptoms of GERD
GERD signs and symptoms include:4
A burning sensation in the chest
(heartburn), sometimes spreading to
the throat, along with a sour taste in
the mouth
Chest pain
Difficulty swallowing (dysphagia), or
food getting stuck
Painful swallowing (odynophagia)
Dry, chronic cough
Hoarseness or sore throat
Regurgitation of food or sour liquid
(acid reflux)
Sensation of a lump in the throat
Stomach pain (or pain in the upper abdomen)
Worsening dental disease
Chronic sinusitis
Waking up with a choking sensation
Nausea
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The most common symptom of GERD is heartburn. Also called acid
indigestion, GERD usually feels like a burning chest pain beginning behind
the breastbone and moving upward to the neck and throat. Many people say
it feels like food is coming back into the mouth leaving an acid or bitter
taste.
The burning, pressure, or pain of heartburn can last as long as two hours
and is often worse after eating. Lying down or bending over can also result
in heartburn. Many people obtain relief by standing upright or by taking an
antacid that clears acid out of the esophagus.
GERD Epidemiology
Gastroesophageal Reflux Disease is caused by frequent acid reflux — the
backup of stomach acid or bile into the esophagus. When a person swallows,
the lower esophageal sphincter — a circular band of muscle around the
bottom part of the esophagus — relaxes to allow food and liquid to flow
down into the stomach. Then it closes again. However, if this valve relaxes
abnormally or weakens, stomach acid can flow back up into the esophagus,
causing frequent heartburn. Sometimes this can disrupt daily life.
This constant backwash of acid can irritate the lining of the esophagus,
causing it to become inflamed (esophagitis). Over time, the inflammation
can wear away the esophageal lining, causing complications such as
bleeding, esophageal narrowing or Barrett's esophagus (a precancerous
condition).4
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Risk Factors
Conditions that can increase the likelihood of having GERD include:4
Obesity
Bulging of top of stomach up into the diaphragm (hiatal hernia)
Pregnancy
Smoking
Dry mouth
Asthma
Diabetes
Delayed stomach emptying
Connective tissue disorders, such as scleroderma
Certain foods – chocolate, peppermint, fried or fatty foods, coffee,
alcoholic beverages
Pressure changes within the esophagus may
be caused externally by the diaphragm, and
result in symptoms as those listed above.
The esophagus passes through an opening
in the diaphragm called the diaphragmatic
hiatus before it joins with the stomach. The
diaphragm is a large flat muscle at the base
of the lungs that contracts and relaxes as a
person breathes in and out.
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Normally, the diaphragm will contract, which improves the strength of the
LES especially during bending, coughing, or straining. If there is a
weakening in the diaphragm muscle at the hiatus, the stomach may be able
to partially slip through the diaphragm into the chest, forming a sliding
hiatus hernia.
The presence of a hiatus hernia makes acid reflux more likely. A hiatus
hernia is more common in people over age 50. Obesity and pregnancy are
also contributing factors. The exact cause is unknown but may be related to
the loosening of the tissues around the diaphragm that occurs with
advancing age. There is no way to prevent a hiatus hernia.3
Hiatal hernias usually do not require treatment. However, treatment may be
necessary if the hernia is in danger of becoming strangulated (twisted in a
way that cuts off blood supply, called a paraesophageal hernia) or is
complicated by severe GERD or esophagitis (inflammation of the
esophagus). The health provider may perform surgery to reduce the size of
the hernia or to prevent strangulation.
Diagnosing GERD
Gastroesophageal reflux disease is usually diagnosed based upon symptoms
and the response to treatment. In people who have symptoms of acid reflux
but no evidence of complications, a trial of treatment with lifestyle changes
and, in some cases, medication is often recommended without testing.
Specific testing is required when the diagnosis is unclear or if there are more
serious signs or symptoms as described above.
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It is important to rule out potentially life threatening problems that can
cause symptoms similar to those of gastroesophageal reflux disease. This is
particularly true with chest pain, which can also be a symptom of heart
disease.. Diagnosis of GERD is based on the following symptoms and
diagnostic testing outcomes.3,4
Symptoms:
Health care providers may be able to diagnose GERD based on
frequent heartburn and other symptoms.
Ambulatory acid (pH) probe tests:
The ambulatory pH test monitors the amount of acid in the esophagus
using a device to measure acid for 24 – 48 hours. The device identifies
when, and for how long, stomach acid regurgitates into the esophagus.
One method, is to insert a thin, flexible pH measuring probe (catheter)
through the nose and thread it past the upper section of the
esophagus to position the tube sensors just above the LES where
reflux may be found to occur.
The pH probe test is generally intended to last 24 hours. The external
portion of the pH probe connects to a small electronic receiver that is
worn around the waist or with a strap over the shoulder to retrieve
data, such as reflux episodes in relation to meals, activities or rest
periods.
Another type of pH test system involves a device that is placed in the
esophagus during endoscopy and adheres to the inner esophageal
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mucosa. The device within the esophagus is designed to remain for 24
to 48 hours and transmits pH data to a small portable receiver that is
worn by the patient. After about two days, the probe falls off the
esophageal mucosa to be passed in the patient’s stool.
Ambulatory pH monitoring is useful for confirming gastroesophageal
reflux disease in those with persistent symptoms (whether typical or
atypical) who do not have evidence of mucosal damage on endoscopy,
particularly if a trial of twice-daily medication has failed. It can also be
used to monitor the adequacy of treatment in those with continued
symptoms. Patients may need to stop taking GERD medications to
prepare for pH testing.
Patients with GERD who are candidates for surgery, may also have other
diagnostic tests, such as:3,4
X-ray of the upper digestive system:
Sometimes called a barium swallow or upper GI series, this procedure
involves drinking a chalky liquid that coats and fills the inside lining of
the digestive tract. A series of X-rays are then taken of the upper
digestive tract. The coating allows medical providers to see a
silhouette of the esophagus, stomach and upper intestine (duodenum).
Endoscopy:
Endoscopy is a diagnostic test using an upper flexible endoscope that
directly visualizes the inside of the esophagus and stomach for routine
screening or initial inspection of a condition. During endoscopy, the
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medical provider inserts a thin, flexible endoscope equipped with a
light source and camera located at the tip of the endoscope insertion
tube down the throat, and passes it into the stomach and often the
upper small bowel (duodenum) is inspected as well.
Upper endoscopy provides a mechanism for detecting, stratifying, and
managing the esophageal manifestations of GERD. On upper
endoscopy, biopsies should target any areas of suspected metaplasia,
dysplasia, or, in the absence of visual abnormalities, normal mucosa.
Providers may also use endoscopy to collect a sample of tissue
(biopsy) for further testing. Endoscopy is useful to look for
complications of reflux, such as esophageal inflammation or Barrett's
esophagus.
Esophageal Manometry (Motility) Testing:
Manometry measures movement and pressure in the esophagus. The
test involves placing a manometry catheter with pressure sensors
through the nose and into the esophagus. Manometry will indicate how
well the esophagus can perform peristalsis.
Manometry also allows the medical provider to examine lower
esophageal sphincter functioning. As the LES relaxes, food and liquid
are allowed to enter the stomach; and, when the LES closes it
prevents food and liquid from moving out of the stomach and back up
the esophagus.
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Complications Of GERD
Over time, chronic inflammation in the esophagus can lead to complications.
These may include the following conditions.3,4
Narrowing of the esophagus (esophageal stricture):
Damage to cells in the lower esophagus from acid exposure leads to
formation of scar tissue. The scar tissue narrows the food pathway,
causing difficulty swallowing.
An open sore in the esophagus (esophageal ulcer):
Stomach acid can severely erode tissues in the esophagus, causing an
open sore to form. The esophageal ulcer may bleed, cause pain and
make swallowing difficult.
Lung and throat problems:
Some people reflux acid into the throat, causing inflammation of the
vocal cords, a sore throat, or a hoarse voice. The acid can be inhaled
into the lungs and cause a type of pneumonia (aspiration pneumonia)
or asthma symptoms. Chronic acid reflux into the lungs may
eventually cause permanent lung damage, called pulmonary fibrosis or
bronchiectasis.
Epidemiologic evidence suggests that 15 million Americans suffer from
asthma, and that 34 to 89 percent of asthmatics have
gastroesophageal reflux disease (irrespective of the use of
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bronchodilators), and that up to 40 percent of asthmatics have peptic
esophagitis.
Pre-cancerous changes to the esophagus (Barrett's esophagus):
In Barrett's esophagus, the tissue lining the lower esophagus changes.
These changes are associated with an increased risk of esophageal
cancer. The risk of cancer is low, but providers will likely recommend
regular screening endoscopy exams to look for early warning signs of
esophageal cancer.
Esophageal cancer:
There are two main types of esophageal cancer: adenocarcinoma and
squamous cell carcinoma. A major risk factor for adenocarcinoma is
Barrett's esophagus, discussed above. Squamous cell carcinoma does
not appear to be related to GERD. Unfortunately, adenocarcinoma of
the esophagus is on the rise in the United States and in many other
countries. However, only a small percentage of people with GERD will
develop Barrett's esophagus and an even smaller percentage will
develop adenocarcinoma.
Treatment Of GERD
Gastroesophageal reflux disease
symptoms of mild heartburn at least
twice per week have been found to
have a considerable effect on quality of
life.7 Medical providers recommend
nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com16 lifestyle and dietary changes for most people needing treatment for GERD. Treatment aims at decreasing the amount of reflux or reducing damage to the lining of the esophagus from refluxed materials. General treatment recommendations for GERD published by the National Institute of Health are useful for primary care clinicians and nurses when educating patients, and the recommendations are outlined below.5 Avoiding foods and beverages that can weaken the LES is often recommended. These foods include chocolate, peppermint, fatty foods, coffee, and alcoholic beverages. Foods and beverages that can irritate a damaged esophageal lining, such as citrus fruits and juices, tomato products, and pepper, should also be avoided if they cause symptoms. Decreasing the size of portions at mealtime may also help control symptoms. Eating meals at least two to three hours before bedtime may lessen reflux by allowing the acid in the stomach to decrease and partial emptying of the stomach. In addition, being overweight often worsens symptoms. Many overweight people find relief when they lose weight. Cigarette smoking weakens the LES. Stopping smoking is important to reduce GERD symptoms. Elevating the head of the bed on six to eight inches or sleeping on a specially designed wedge reduces heartburn by allowing gravity to minimize reflux of stomach contents into the esophagus. It is not recommended to use pillows to prop oneself up; that position only increases pressure on the stomach. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com
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Along with diet and lifestyle changes, treatment for heartburn and other
signs and symptoms of GERD usually begins with over-the-counter
medications that control acid. If patients are not able to experience relief
within a few weeks, health care providers may recommend other
treatments, including medications and surgery. Over-the-counter treatments
may help control heartburn. These treatments are briefly outlined below.5
Antacids that neutralize stomach acid:
Antacids, such as Maalox, Mylanta, Gelusil, Gaviscon, Rolaids and
Tums, may provide quick relief. But antacids alone are not expected to
heal an inflamed esophagus damaged by stomach acid. Overuse of
some antacids can cause side effects, such as diarrhea or constipation.
Medications to reduce acid production:
Called H-2-receptor (histamine H-2) blockers, these medications
include cimetidine (Tagamet HB), famotidine (Pepcid AC), nizatidine
(Axid AR) or ranitidine (Zantac). The H-2-receptor blockers do not act
as quickly as antacids do, but they provide longer relief and may
decrease acid production from the stomach for up to 12 hours.
Stronger versions of these medications are available in prescription
form.
Medications that block acid production and heal the esophagus:
Proton pump inhibitors (PPI) are stronger blockers of acid production
than are H-2-receptor blockers and allow time for damaged
esophageal tissue to heal. Over-the-counter proton pump inhibitors
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include lansoprazole (Prevacid 24 HR) and omeprazole (Prilosec,
Zegerid OTC).
Once the optimal dose and type of PPI is found, the patient will
probably be kept on the PPI for approximately eight weeks. Depending
upon the symptoms after eight weeks, the medication dose may be
decreased or discontinued. If symptoms return within three months,
long-term treatment is usually recommended. If symptoms do not
return within three months, treatment may be needed only
intermittently. The goal of treatment for GERD is to take the lowest
possible dose of medication that controls symptoms and prevents
complications.
Proton pump inhibitors are safe, although they may be expensive,
especially if taken for a long period of time. Long-term risks of PPIs
may include an increased risk of gut infections, such as Clostridium
difficile (C. diff), or reduced absorption of minerals and nutrients. In
general, these risks are small. However, even a small risk emphasizes
the need to take the lowest possible dose for the shortest possible
time.
If heartburn persists despite initial approaches, health care providers may
recommend prescription-strength medications, which are outlined below.4,6
Prescription-strength H-2-receptor blockers:
These include prescription-strength cimetidine (Tagamet), famotidine
(Pepcid), nizatidine (Axid) and ranitidine (Zantac).
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Prescription-strength proton pump inhibitors:
Prescription-strength proton pump inhibitors include esomeprazole
(Nexium), lansoprazole (Prevacid), omeprazole (Prilosec, Zegerid),
pantoprazole (Protonix), rabeprazole (Aciphex) and dexlansoprazole
(Dexilant). These medications are generally well tolerated, but long-
term use may be associated with a slight increase in risk of bone
fracture and vitamin B-12 deficiency.
Medications to strengthen the lower esophageal sphincter:
Baclofen may decrease the frequency of relaxations of the lower
esophageal sphincter and therefore decrease gastroesophageal reflux.
It has less of an effect than proton pump inhibitors, but it might be
used in severe reflux disease. Baclofen can be associated with
significant side effects, most commonly fatigue or confusion.
Medication for gastroesophageal reflux disease is sometimes combined to
increase effectiveness. Most GERD symptoms can be controlled through
medications. In situations where medications are not helpful or there is a
desire to avoid long-term medication use, health care providers may
recommend more-invasive procedures, briefly outlined below.4,6
Surgery to reinforce the lower esophageal sphincter (Nissen
fundoplication):
Fundoplication surgery involves tightening the lower esophageal
sphincter to prevent reflux by wrapping the very top of the stomach
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around the outside of the lower esophagus. Surgeons usually perform
this surgery laparoscopically. In laparoscopic surgery, the surgeon
makes three or four small incisions in the abdomen and inserts
instruments, including a flexible tube with a tiny camera, through the
incisions.
Though the outcome of surgery is usually good, complications can
occur. Examples include persistent difficulty swallowing (occurring in
about five percent of patients), a sense of bloating and gas (known as
"gas-bloat syndrome"), breakdown of the repair (one to two percent of
patients per year), or diarrhea due to inadvertent injury to the nerves
leading to the stomach and intestines.
Surgery to strengthen the lower esophageal sphincter (Linx):
The Linx device is a ring of tiny magnetic titanium beads that is
wrapped around the junction of the stomach and esophagus. The
magnetic attraction between the beads is strong enough to keep the
opening between the two closed to refluxing acid, but weak enough so
that food can pass through it.
The Linx device can be implanted using minimally invasive surgery
methods. The U.S. Food and Drug Administration approved this newer
device and early studies on its efficacy to control GERD appear
promising.
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Summary
The passage of gastric contents into the esophagus (gastroesophageal
reflux) is a normal physiologic process. Most episodes are brief and do not
cause symptoms, esophageal injury, or other complications.
Gastroesophageal reflux becomes a disease when it either causes
macroscopic damage to the esophagus or causes symptoms that reduce the
quality of life.
International gastroenterology experts have identified that GERD symptoms
of mild heartburn at least twice per week can have considerable impact on
quality of life. This course has discussed the diagnosis, risk factors, causes,
symptoms, complications and treatment of gastroesophageal reflux disease,
which affects up to 10 million adults in the United States on a daily basis.
Please take time to help NurseCe4Less.com course planners evaluate
the nursing knowledge needs met by completing the self-assessment
of Knowledge Questions after reading the article, and providing
feedback in the online course evaluation.
Completing the study questions is optional and is NOT a course
requirement.
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1. GERD affects up to _________ adults in the United States on a daily
basis.
a. 3.5 million
b. 5 million
c. 6.8 million
d. 10 million
2. The esophagus is a tube-like structure that is approximately _____
inches long and one _____ inch wide in adults.
a. 15 (inches long) and 2 (inch wide)
b. 13 (inches long) and 3 (inch wide)
c. 10 (inches long) and 1 (inch wide)
d. none of the above
3. The LES _________ to allow food/liquid to flow down into the stomach.
a. contracts
b. has peristalsis similar to esophagus
c. relaxes
d. None of the above
4. GERD is managed by most people with:
a. over the counter medication
b. PPIs
c. life style changes
d. answers a and c above
5. Barrett's esophagus is associated with an increased risk of:
a. acid reflux
b. aspiration pneumonia
c. high incidence of malignancy
d. esophageal cancer
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6. GERD symptoms can include:
a. burning sensation in the chest
b. difficulty swallowing
c. nausea
d. All of the above
7. Omeprazole is an example of a(n):
a. Antacid (over the counter)
b. H2 blocker
c. Proton pump inhibitor
d. Either a or b above
8. ___________ is implanted using minimally invasive surgery methods
and approved by the FDA to prevent reflux.
a. Nissan device
b. Linx device
c. pH probe device
d. none of the above
9. H-2-receptor blockers do not act as quickly as antacids do, but provide
longer relief and may decrease acid production up to ______ hours.
a. 6
b. 24
c. 8
d. 12
10. True/False. Pregnancy is a risk factor for individuals to develop GERD.
a. True
b. False
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11. Ambulatory pH monitoring is useful for confirming GERD in patients with
a. atypical symptoms only
b. typical symptoms only
c. persistent symptoms and failed trial of twice daily medication
d. None of the above
12. Head of the bed elevation ___________ helps reduce GERD symptoms.
a. 4 – 5 inches
b. 6 – 8 inches
c. with a pillow
d. Answers a and c above
13. A reported complication of Nissen fundoplication is:
a. obstruction
b. severe chest pain
c. gas-bloat syndrome
d. None of the above
14. True/False. GERD medications should be never combined for continued
symptoms.
a. True
b. False
15. PPIs have been associated with slight increase in risk of bone fracture
and vitamin B-12 deficiency.
a. True
b. False
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CORRECT ANSWER KEY:
1. GERD affects up to _________ adults in the United States on a daily
basis.
Correct Answer: 10 million
2. The esophagus is a tube-like structure that is approximately _____
inches long and one _____ inch wide in adults.
Correct Answer: 10 (inches long) and 1 (inch wide)
3. The LES _________ to allow food/liquid to flow down into the stomach.
Correct Answer: relaxes
4. GERD is managed by most people with:
Correct Answer: answers a and c above
5. Barrett's esophagus is associated with an increased risk of:
Correct Answer: esophageal cancer
6. GERD symptoms can include:
Correct Answer: all of the above
7. Omeprazole is an example of a(n):
Correct Answer: Proton pump inhibitor
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8. The ______________ is implanted using minimally invasive surgery
methods and approved by the FDA to prevent reflux.
Correct Answer: Linx device
9. H-2-receptor blockers do not act as quickly as antacids do, but provide
longer relief and may decrease acid production up to ______ hours.
Correct Answer: 12
10. True/False. Pregnancy is a risk factor for individuals to develop GERD.
Correct Answer: True
11. Ambulatory pH monitoring is useful for confirming GERD in patients with
Correct Answer: persistent symptoms and failed trial of twice daily
medication
12. Head of the bed elevation ___________ helps reduce GERD symptoms.
Correct Answer: 6 – 8 inches
13. A reported complication of Nissen fundoplication is:
Correct Answer: gas-bloat syndrome
14. True/False. GERD medications should be never combined for continued
symptoms.
Correct Answer: False
15. PPIs have been associated with slight increase in risk of bone fracture
and vitamin B-12 deficiency.
Correct Answer: True
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References Section
The reference section of in-text citations include published works intended as
helpful material for further reading. Unpublished works and personal
communications are not included in this section, although may appear within
the study text.
1. Kahrilas, P.J. (2015). Patient information: Acid reflux (gastroesophageal
reflux disease) in adults (Beyond the Basics). UpToDate. Waltham,
Mass: UpToDate. Retrieved online October 23, 2015 from
www.uptodate.com.
2. de Bertoli, N., et al. (2013). Overlap of functional heartburn and
gastroesophageal reflux disease with irritable bowel syndrome. World J
Gastroenterol 2013 September 21; 19(35): 5787-5797
3. Kahrilas, P.J. (2015). Clinical manifestations and diagnosis of
gastroesophageal reflux in adults in Talley, N.J. (Ed.), UpToDate.
Waltham, Mass: UpToDate. Retrieved October 19, 2015 from
www.uptodate.com
4. GERD (2014). Mayo Foundation for Medical Education and Research.
Retrieved October 18, 2015 from www.mayoclinic.org
5. Gastroesophageal Reflux (GER) and Gastroesophageal Reflux Disease
(GERD) in Adults. (2014). National Institute of Diabetes and Digestive
and Kidney Diseases. Retrieved October 18, 2015 from
www.niddk.nih.gov
6. Kahrilas, P.J. (2015). Medical Management of gastroesophageal reflux in
adults in Talley, N.J. (Ed.), UpToDate. Waltham, Mass: UpToDate.
Retrieved October 19, 2015 from www.uptodate.com
nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com28
7. Tamura, Y., et al. (2015). Pathophysiology of functional heartburn based
on Rome III criteria in Japanese patients. World J Gastroenterol. 2015
Apr 28; 21(16): 5009–5016.
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