Teaching practice on esophageal obstruction and esophageal stricture

Submitted by, Mrs Bibi Baby 2 nd year MSc Nursing Medical Surgical Nursing PION.

Submitted to, Mrs. Prasanna Balaji HOD of Medical Surgical Nursing PION. ESOPHAGEAL OBSTRUCTION AND ESOPHAGEAL STRICTURE

Introduction The esophagus is a mucus lined , muscular tube that carriers food from the mouth to the stomach. It begins at the base of the pharynx and ends about 4 cm below the diaphram. Its ability to transport food and fluid is facilitated by two sphincters that is hypopharyngeal sphincter which is located at junction of pharynx and esophagus and gastro esophageal sphincter which is located at junction of esophagus and stomach. ESOPHAGEAL OBSTRUCTION Definition Esophageal obstruction is the name given to a medical emergency that results when a food bolus or other foreign body fails to pass through the esophagus and becomes lodged on its lumen instead. It is commonly known as "steakhouse syndrome", since meats such as steak, poultry or pork are among the most common foods that can trigger the syndrome. This is usually recognized by the abrupt onset of a difficulty in swallowing, which prevents the subsequent passage of food through the esophagus and results in the need for emergency Incidence Esophageal obstruction is directly associated with episodes of food ingestion and it occurs more frequently in adults, although it is occasionally observed in children too. Etiology Large food bolus with no underlying cause Strictures or stenosis Carcinoma Shatzkis ring (15% of people have fibrous stricture near GE junction)

 Esophageal webs (Plummer vinson syndrome: iron deficiencyanemia, dysphagia, cheliosis,glossitis, friable mucosa.) Zenkers diverticulum: outpouching of pharyngeal mucosa b/c of improper relaxation of the cricopharyngeus muscle; may feel a mass in the neck. Anomalous right subclavian artery is the MC vascular cause Goiter Foreign bodies Clinical manifestations
Difficulty Swallowing/Choking (dysphagia) Drooling Chest Pain Neck Pain Abdominal Pain

Heartburn
Gastroesophageal Reflux Painful Swallowing (odinophagia) Asthma Diagnosis

Endoscopy . X-ray. C T Scan. MRI

Management Medical management Obstruction of the esophagus represents a potentially serious medical problem. The choice of treatment depends on the specific characteristics of the case, including the nature of the obstructing object. 1. If the object presents sharp edges (such as bony material) or has a corrosive capacity

(batteries, for example), it should be removed urgently. The standard method of removal in these cases is rigid oesophagoscopy under general anaesthetic. 2. 3. esophageal obstructions in patients with a non-sharp food bolus are known to Numerous techniques have been proposed to induce spontaneous resolution of the eventually pass spontaneously, and therefore management guidelines are less clear in this case obstruction without resorting to endoscopy, including the blind insertion of Maloney dilators and nasogastric tubes to push the object into the stomach. This is known as the "push technique". 4. 5. Another alternative to treating esophageal obstruction is the insertion of a Foleys Pharmacological techniques have also been advanced as a potential solution for catheter in order to extract the foreign body. esophageal obstruction. These include agents that alter the muscular tone of the esophagus, allowing the foreign body to pass, and enzymatic digestion of the bolus by the use of carbonated beverages such as Coca-Cola or mixtures of citric acid and sodium bicarbonate solutions. Surgical management In the event of a failure of medical management, Endoscopic removal using either rigid or flexible techniques remains the mainstay of treatment for esophageal obstruction. A wide range of endoscopic devices, including rat-

tooth forceps, Dormia baskets, polypectomy snares, and different sizes of Roth net are suitable for surgical removal of the obstruction. Roth nets are particularly useful in the case of obstructions provoked by food boluses because they can be contained completely within the net, thus avoiding the use of general anesthesia or an overtube and minimizing the risk of aspiration. Complication 1. Esophageal perforation . 2. Mediastinitis . 3. Intestinal perforation Nursing management 1. Advice the patients to avoiding swallowing large chunks of food without proper chewing, especially when dealing with meat. 2. A number of underlying conditions that contribute to the narrowing of the esophageal lumen increase the chances of an episode, and therefore careful monitoring and treatment for these conditions can prevent its occurrence. 3. Reflux of stomach acid to the esophagus can cause inflammation and scarring, a condition known as acid peptic stricture. The fibrous scar then contracts and narrows the esophageal opening. 4. Effective acid-suppressive therapy with proton pump inhibitors is an effective way to keep the symptoms under control and prevent a potential esophageal obstruction. 5. Accidental foreign body ingestion is another common cause of esophageal obstruction, particularly in children aged 6 months to 3 years. 6. Careful monitoring of children during this developmental period and removing from their reach those objects that can pose a threat due to their size and shape are obvious measures to be taken in order to prevent obstructions. 7. In particular, young children seem to be very prone to swallowing liquid lye and other caustic agents that can severely burn the esophagus, leaving it narrowed and prone to obstruction.

ESOPHAGEAL STRICTURE Definition An esophageal stricture is a gradual narrowing of the esophagus, which can lead to swallowing difficulties. The strictures are caused by scar tissue that builds up in the esophagus.

Incidence It affects approximately 40% of adults. Strictures occur in 7 to 23% of patients with GERD who are untreated. Causes

Gastroesophageal reflux (GERD) Prolonged use of a nasogastric tube Ingestion of corrosive substances Viral or bacterial infections Injuries caused by endoscopes

Pathophysiology
When the lining of the esophagus is damaged, Scarring develops. When scarring occurs, the lining of the esophagus becomes stiff. As this scar tissue continues to build up, The esophagus begins to narrow in that area. The result then is swallowing difficulties.

Clinical manifestations

Chest pain after swallowing

Difficulty swallowing Discomfort with swallowing A felling that food gets stuck in the esophagus Regurgitation of food Weight loss Upper back pain after swallowing Hiccups

Diagnosis

A barium swallow. Patient will swallow barium and x-rays can be taken to show the narrowing of the esophagus. An endoscopy exam. This narrow tube is inserted into the esophagus and it can show any narrowing of the esophagus.

Medical management

Dilation. The esophagus is stretched by the use of one of several methods. Two of the methods of dilation are performed by passing a dilator or air-filled balloon is passed through a endoscope. Repeated dilation may be necessary to prevent the stricture from returning. Proton pump inhibitors, such as omeprazole, lansoprazole or rabeprazole, can keep strictures from returning.

Surgical management

Surgical treatment is rarely necessary. If is performed if a stricture can't be dilated enough to allow solid food to pass through. Surgery is also performed if repeated dilations do not keep these strictures from returning.

Complications

Swallowing difficulties may keep the patient from getting enough fluids and nutrients. Increased risk of regurgitated food, fluid, or vomit entering the lungs and cause choking or aspiration pneumonia

Nursing management 1. Maintain strict intake and output chart,check weight daily. 2. Advice the patient to be upright for 4 hours after each meal to prevent reflex. 3. The head of the bed should be placed with 4 to 8 inch blocks. 4. Provide antacids as per physician orders as it can cause rebound activity 5. Provide fowlers position to decrease aspiration

6. Advice the patients to avoid Irritants such as tobacco and alcohol.

7. Small frequent feeding of non irritating foods are recommended to promote digestion Nursing diagnosis 1. Imbalanced nutrition less than body requirement related to difficulty in swallowing. Interventions a. The patient should be encouraged to eat slowly and chew food thoroughly so that it can pass early into the stomach. b. Small frequent feeding of non irritating foods are recommended to promote digestion. c. Food should be prepared in an appealing manner to help to stimulate appetite. d. Irritants such as tobacco and alcohol should be avoided. e. Daily weight should be recorded with intake and output chart.

2. Acute pain related to difficulty swallowing , ingestion of an abrasive agent or to tube feeding.
Interventions

a. Small and frequent feeding (six to eight per day).

b. Advice to patient not to do any activities that cause pain. c. Advice the patient to be upright for 4 hours after each meal to prevent reflex. d. The head of the bed should be placed 4 to 8 inch blocks. e. Eating before bedtime is discouraged.

f. Provide antacids as per physician orders as it can cause rebound activity.

3. Risk of aspiration related to difficulty swallowing or to tube feeding. Interventions a. Provide fowlers position to decrease aspiration. b. Provide oral suction as needed. 4. Knowledge deficit regarding treatment regimen and lifestyle changes. Interventions a. Reassure the patient by explaining the procedures and their purposes. b. Provide emotional and psychological support. c. Prepare the patient physically and psychologically for diagnostic tests, treatments and possible surgery.

BIBLIOGRAPHY

1) Suzanne C, Brend G. Medical surgical nursing. 10th edition. Philadelphia: Lippincott William & Wilkins; 2004 .

2) Lewis, Heitkemper, Dirksen, OBrien, Bucher. Medical surgical nursing. 7th edition. Missouri: Elsevier; 2008. 3) Ignatavicius D, Workman L, Mishler A. Medical surgical nursing. 2nd edition. Philadelphia: W.B Saunders company; 2000. 4) Doenges E, Moorhouse F, Murr C. Nursing care plans. 7th edition. New delhi: Jaypee Brothers; 2007. 5) Esophageal stricture; available at http://en.wikipedia.org/wiki/Esophageal_stricture