Disorders of the Esophagus:
Achalasia ,Esophageal Spasm and Hiatal
Hernia
PREPARED BY: KHALIL G. MAGUMPARA, RN
Achalasia:
Achalasia is a rare esophageal motility
disorder characterized by the inability of the
lower esophageal sphincter (LES) to relax
properly and the absence of coordinated
peristaltic contractions in the esophageal body.
Achalasia is a primary esophageal motility disorder
characterized by the absence of esophageal peristalsis
and impaired relaxation of the lower esophageal
sphincter (LES) in response to swallowing.
Clinical Manifestations:
Dysphagia (difficulty swallowing), especially
for solid foods.
Regurgitation of undigested food.
Chest pain or discomfort, often mistaken
for angina.
Weight loss due to reduced food intake.
Assessment and Diagnostic Findings:
Barium swallow test to visualize esophageal
motility.
Esophageal manometry to measure pressure
and muscle function.
Endoscopy to rule out other conditions.
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Management:
Medical: Nitrates or calcium channel
blockers to relax the esophagus.
Botulinum Toxin Injection: Temporarily
paralyzes the lower esophageal sphincter
muscle.
Pneumatic Balloon Dilation: Widening the
lower esophageal sphincter by inflating a
balloon.
Surgical: Heller myotomy (cutting the
muscle fibers of the lower esophageal
sphincter) or laparoscopic surgery.
Esophageal Spasm: Esophageal spasm refers
to abnormal contractions of the smooth
muscles in the esophagus. These
contractions can be uncoordinated and overly
strong, leading to chest pain, discomfort, and
dysphagia.
Esophageal spasm can be categorized into two
main types:
diffuse esophageal spasm (DES),
characterized by irregular and simultaneous
contractions throughout the esophagus,
nutcracker esophagus,
which involves high-amplitude contractions in
the lower esophagus.
These spasms can result in a sensation of food
getting stuck in the chest and may mimic
symptoms of heart-related chest pain (angina).
Esophageal spasms are painful contractions within the
muscular tube connecting your mouth and stomach. This
tube is called the esophagus. Esophageal spasms can feel
like sudden, severe chest pain that lasts from a few
minutes to hours. Some people may mistake it for heart
pain, also called angina.
Clinical Manifestations:
Chest pain or discomfort, often described
as squeezing or burning.
Dysphagia (difficulty swallowing).
Regurgitation.
Assessment and Diagnostic Findings:
Manometry to assess esophageal muscle
contractions.
Barium swallow to identify abnormalities during
swallowing.
Endoscopy to rule out other conditions.
Nursing Management:
Assessment: Assess for dysphagia,
regurgitation, chest pain, and weight loss.
Nutritional Support: Collaborate with
dietitians to plan a diet that meets nutritional
needs while considering swallowing difficulties.
Medication Education: Educate patients
about prescribed medications, their purpose,
and potential side effects.
Prevent Aspiration: Elevate the head of the
bed during meals to prevent reflux and
aspiration.
Emotional Support: Address patient's anxiety,
stress, and concerns related to eating and
symptoms.
Preoperative and Postoperative Care: If
surgical intervention is needed, provide
preoperative and postoperative care, including
wound care and pain management.
Patient Education: Teach patients about
dietary modifications, proper chewing
techniques, and strategies to manage
symptoms.
Follow-Up: Ensure patients attend follow-up
appointments, monitor progress, and adjust
interventions as needed.
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Hiatal Hernia:
is a condition in which a portion of the stomach protrudes
through the diaphragm and into the chest cavity,
typically through the esophageal hiatus (an opening in the
diaphragm through which the esophagus passes).
Causes:
Weakness in the diaphragm:
The primary cause is a weakening of the diaphragm muscle,
which may occur due to aging, injury, or congenital factors.
Increased abdominal pressure:
Factors such as obesity, pregnancy, heavy lifting, or
straining during bowel movements can increase intra-
abdominal pressure and contribute to the development of a
hiatal hernia.
Risk Factors:
• Age: Hiatal hernias are more common in older adults.
• Obesity: Excess body weight can increase abdominal
pressure.
• Smoking: Smoking weakens the lower esophageal sphincter
(LES), allowing stomach acid to flow into the esophagus.
• Pregnancy: The growing uterus can push the stomach
upward.
• Certain activities: Heavy lifting or straining can contribute
to hernia development.
Pathophysiology:
A hiatal hernia occurs when the stomach or a portion of the
stomach moves above the diaphragm, disrupting the normal
anatomy of the esophagus and stomach.
This can lead to the weakening of the lower esophageal
sphincter, allowing stomach acid to reflux into the
esophagus, causing symptoms like heartburn.
Clinical Manifestations: Common symptoms of hiatal
hernia include:
• Heartburn: A burning sensation in the chest, especially
after eating or lying down.
• Regurgitation: The backflow of stomach contents into the
throat.
• Chest pain: May mimic heart-related chest pain (angina).
• Difficulty swallowing: Due to the herniated portion of the
stomach pressing on the esophagus.
• Belching or hiccups: Frequent burping or hiccups.
A hiatal hernia occurs when part of the stomach protrudes up
into the chest through the sheet of muscle called the
diaphragm. This may result from a weakening of the
surrounding tissues and may be aggravated by obesity and/or
smoking. The esophagus runs through the diaphragm to the
stomach.
These types
Sliding Hiatal Hernia (Type I):
• the gastroesophageal junction (where the esophagus meets
the stomach) and a portion of the stomach slide upward
through the esophageal hiatus (the opening in the
diaphragm) into the chest cavity.
• This is the most common type of hiatal hernia.
• Pathophysiology:
• The movement of the stomach and the lower part of the
esophagus into the chest is usually accompanied by a
weakening of the lower esophageal sphincter (LES), which
can contribute to acid reflux and related symptoms.
Clinical Manifestations:
Sliding hiatal hernias can cause symptoms such
as heartburn, regurgitation, chest pain, and
difficulty swallowing.
Paraesophageal (Rolling) Hiatal Hernia (Type II-IV):
• Definition:
• In paraesophageal or rolling hiatal hernias, a portion of the
stomach pushes through the diaphragm alongside the
esophagus,
• rather than sliding through the esophageal hiatus. This type
is less common but can be more concerning.
• Pathophysiology:
• In paraesophageal hernias, the gastroesophageal junction
remains in its normal location, but a portion of the stomach
herniates next to the esophagus. This can lead to
complications if the herniated stomach becomes trapped or
twisted.
Clinical Manifestations:
Symptoms may be less pronounced in
paraesophageal hernias, but patients can still
experience discomfort, chest pain, and
difficulty swallowing. There is a risk of more
severe complications, such as gastric
strangulation, in paraesophageal hernias.
Paraesophageal hernias are further classified into types II,
III, and IV based on the extent of herniation and the
involvement of other abdominal organs.
• Type II: Part of the stomach herniates next to the esophagus,
but the gastroesophageal junction remains in place.
• Type III: The gastroesophageal junction and a portion of the
stomach herniate into the chest.
• Type IV: The gastroesophageal junction and other
abdominal organs, such as the colon or small intestine,
herniate into the chest.
Assessment and Diagnostic Findings:
• Clinical history and physical examination: Evaluation of
symptoms, risk factors, and physical signs.
• Upper endoscopy: Direct visualization of the esophagus
and stomach.
• Barium swallow: X-ray using contrast material to highlight
the esophagus and stomach.
• Esophageal pH monitoring: Measures acid reflux into the
esophagus.
• Manometry: Assesses esophageal muscle function.
Types of Surgery: Surgery is considered for severe cases or
when conservative measures fail. Two common surgical
approaches include:
Nissen fundoplication:
Wraps the top of the stomach around the lower esophagus to
reinforce the LES and prevent reflux.
Hernia repair:
Repositions the stomach and repairs the hiatal hernia
opening in the diaphragm.
A Nissen fundoplication is a surgery to correct
gastroesophageal reflux disease (GERD). The surgery
tightens the junction between the esophagus and the
stomach to prevent acid reflux. The esophagus is the tube
between your mouth and stomach
Medical Management:
• Lifestyle modifications: Dietary changes (avoiding trigger
foods, smaller meals), weight loss, and elevation of the head
of the bed.
• Medications: Proton pump inhibitors (PPIs) or H2-receptor
antagonists to reduce stomach acid.
• Antacids: For symptom relief.
• Prokinetic agents: To improve esophageal motility.
Nursing Management:
• Assessment: Document symptoms, vital signs, and response
to treatments.
• Education: Provide information about dietary
modifications, medications, and lifestyle changes.
• Medication administration: Ensure proper dosing and
timing of medications.
Positioning: Advise patients to avoid lying
down immediately after eating and elevate the
head of the bed.
Emotional support: Address anxiety and
concerns related to the condition.
Postoperative care: If surgery is performed,
monitor for complications, and educate the
patient on post-op care.
