In gastro-esophageal reflux disease (GERD) stomach contents flow back (reflux) from the stomach (gastro) into the esophagus (esophageal). Stomach contents contain acid. The acid can irritate and inflame the esophagus lining. This is called esophagitis—inflammation (itis) of the esophagus.

Heartburn is the most common symptom of GERD. Heartburn is a burning sensation in the chest and sometimes the throat. The person may have a sour taste in the back of the mouth. Occasional heartburn is not a problem. If it occurs more than twice a week, the person may have GERD. Besides heartburn, other signs and symptoms of GERD include:

• Chest pain, often when lying down

• Hoarseness in the morning

• Dysphagia

• Choking sensation

• Feeling like food is stuck in the throat

• Feeling like the throat is tight

• Dry cough

• Sore throat

• Bad breath

GERD risk factors include being over-weight, alcohol use, pregnancy, and smoking. Hiatal hernia is a risk. With hiatal hernia, the upper part of the stomach is above the diaphragm. Large meals and lying down after eating can cause gastric reflux. So can certain foods—citrus fruits, chocolate, caffeine drinks, fried and fatty foods, garlic, onions, spicy foods, tomato-based foods (pasta sauce, chili, pizza).

The doctor may order medications to prevent stomach acid production or to promote stomach emptying. Surgery may be needed if medications and life-style changes do not work. Life-style changes include:

• No smoking

• Not drinking alcohol

• Losing weight

• Eating small meals

• Wearing loose belts and loose-fitting clothes

• Not lying down for 3 hours after meals

• Raising the head of the bed 6 to 8 inches. See “reverse Trendelenburg’s position” in Chapter 18.

Vomiting

Vomiting means expelling stomach contents through the mouth. It signals illness or injury. Vomitus (emesis) is the food and fluids expelled from the stomach through the mouth. Aspirated vomitus can obstruct the airway. Vomiting large amounts of blood can lead to shock. These measures are needed:

• Follow Standard Precautions and the Bloodborne Pathogen Standard.

• Turn the person’s head well to one side. This prevents aspiration.

• Place a kidney basin under the person’s chin.

• Move vomitus away from the person.

• Provide oral hygiene. This helps remove the bitter taste of vomitus.

• Observe vomitus for color, odor, and undigested food. If it looks like coffee grounds, it contains undigested blood. This signals bleeding. Report your observations.

• Measure, report, and record the amount of vomitus. Also record the amount on the I&O (intake and output) record.

• Save a specimen for laboratory study.

• Dispose of vomitus after the nurse observes it.

• Eliminate odors.

• Provide for comfort. (See the inside of the front book cover.)

Diverticular disease

Small pouches can develop in the colon. The pouches bulge outward through weak spots in the colon (Fig. 41-1). Each pouch is called a diverticulum. (Diverticulare means to turn inside out.) Diverticulosis is the condition of having these pouches. (Osis means condition of.) The pouches can become infected or inflamed—diverticulitis. (Itis means inflammation.)

Fig. 41-1 Diverticulosis. (From Christensen BL, Kockrow EO: *Adult health nursing,* ed 6, St Louis, 2011, Mosby.)

About half of all people over 60 years of age have diverticulosis. Age, a low-fiber diet, and constipation are risk factors.

When feces enter the pouches, they can become inflamed and infected. The person has abdominal pain and tenderness in the lower left abdomen. Fever, nausea and vomiting, chills, cramping, and constipation are likely. Bloating, rectal bleeding, frequent urination, and pain while voiding can occur.

A ruptured pouch is a rare complication. Feces spill out into the abdomen. This leads to a severe, life-threatening infection. A pouch also can cause a blockage in the intestine (intestinal obstruction). Feces and gas cannot move past the blocked part.

Dietary changes are ordered. Sometimes antibiotics are ordered. Surgery is needed for severe disease, obstruction, and ruptured pouches. The diseased part of the bowel is removed. Sometimes a colostomy is necessary (Chapter 23).

Gallstones

Bile is a greenish liquid made in the liver. It is stored in the gallbladder until needed to digest fat. Gallstones form when the bile hardens into stone-like pieces (Fig. 41-2).

Bile is carried from the liver to the gallbladder through ducts (tubes). The gallbladder contracts and pushes bile through the common bile duct to the small intestine. Gallstones can lodge in any of the ducts (Fig. 41-3). Bile flow is blocked. The trapped bile can cause inflammation of the gallbladder and the ducts. Liver and pancreas involvement are possible. Death can result from severe infections or damage.

Fig. 41-3 The gallbladder and ducts that carry bile from the liver, gallbladder, and pancreas to the small intestine. (Modified from National Digestive Diseases Information Clearinghouse [NDDIC]: *Gallstones,* National Institutes of Health, NIH Publication No. 07-2897, Bethesda, Md, July 2007.)

Gallstones vary in size. They can be as small as a grain of sand or as large as a golf ball. A person may have one large stone. Some people have large and small stones. Risk factors include:

• Gender. Women are at greater risk than men.

• Family history. A genetic link is possible.

• Diet. A diet high in fat and cholesterol increases the risk. So does a low-fiber diet.

• Age. People over age 60 are at greater risk than younger people.

• American Indians. They have genetic factors that increase the risk of gallstones. High levels of cholesterol are secreted into the bile.

• Mexican Americans. Men and women of all ages are at risk.

• Being over-weight. Increased cholesterol reduces gallbladder emptying.

• Rapid weight loss and fasting. To burn fat, the liver secretes more cholesterol into the bile. Cholesterol can cause gallstones. And the gallbladder does not empty properly.

• Cholesterol-lowering medications. They increase the amount of cholesterol secreted into bile.

• Diabetes. Persons with diabetes have high levels of fatty acids. The fatty acids may increase the risk of gallstones.

Signs and symptoms of a “gallbladder attack” or “gallstone attack” occur suddenly (Box 41-1, p. 628). They often follow a fatty meal. The most common treatment is surgical removal of the gallbladder.

Box 41-1

Signs and Symptoms of Gallstones

• Steady pain in the upper abdomen

• Increases rapidly

• Lasts 30 minutes to several hours

• Pain

• In the back between the shoulder blades

• Under the right shoulder

• Prolonged pain—lasting more than 5 hours

• Nausea and vomiting

• Chills

• Fever

• Jaundice—yellowish color of the skin or whites of the eyes (Fig. 41-4) (Jaundice comes from the French word jaune meaning yellow.)

• Clay-colored stools

Modified from National Digestive Diseases Information Clearinghouse (NDDIC): Gallstones, National Institutes of Health, NIH Publication No. 07-2897, Bethesda, Md, July 2007.