Oral Cavity and Pharynx

Changes in the oral cavity have an effect not only on an older person’s well being, comfort, and health, but also on overall nutrition and digestion. The most obvious change in the mouth is the loss of teeth. One fourth of adults who are 65 or older are edentulous (without teeth). More than 7000 people, mainly elderly, die each year from pharyngeal and oral cancers. Periodontal gum disease caused by bacterial infection under the gum destroys both bone and gum. Teeth become loose, chewing becomes more difficult, and often the teeth must be extracted (Centers for Disease Control and Prevention [CDC], 2009a).

Taste buds may atrophy with age, resulting in an inability to discriminate among flavors, especially salty and sweet. This may contribute to decreased enjoyment of food, resulting in poor eating habits and nutritional deficiencies. Medications such as diuretics, anticholinergics, certain antidepressants and antipsychotics reduce saliva production and oral lubrication, which normally function to protect the oral tissues (Lewis, Heitkemper, Dirksen, & O’Brien, 2007).

Healthy People 2010 reflects on the importance of oral health as an integral component of healthy life. Poor oral health and disease conditions have a significant impact on the older adult’s feelings of self-esteem and depression. One of the goals of Healthy People 2010 is to improve access to preventive oral care and early intervention services for older adults (US Department of Health and Human Services, 2000).

Esophagus

Many of the age-related changes in the esophagus result in a decline in its motility. Degenerative changes in the smooth muscle lining the lower esophagus may contribute to a decrease in the strength of esophageal contractions and sphincter weakness. This condition, referred to as presbyesophagus, causes older adults to be more prone to reflux of acid from the stomach or gastroesophageal reflux (LeMone & Burke, 2008). Neurogenic, hormonal, and vascular changes may also contribute to a decrease in esophageal motility. These changes may lead to complaints of dysphagia, heartburn, or vomiting of undigested foods. Subsequently, poor nutrition, dehydration, and decreased food intake often result.

Stomach

Age-related changes in the stomach include degeneration of the gastric mucosa, decreased secretion of gastric acids and digestive enzymes, and decreased motility (Lewis et al, 2007). The stomach of an older adult is not able to accommodate large amounts of food because of decreased elasticity. The ability to empty gastric contents as quickly is also diminished in the older adult, which quickly results in a feeling of fullness or early satiation.

By the age of 60, gastric secretions decrease to 70% to 80% of those of the average adult. A decrease in pepsin may hinder protein digestion, whereas a decrease in hydrochloric acid and intrinsic factor may lead to malabsorption of iron, vitamin B₁₂, calcium, and folic acid. This, combined with atrophy of the mucosa and a decrease in gastric secretions, increases the incidence of pernicious anemia, peptic ulcer disease (PUD), and stomach cancer.

Small Intestine

Age-related changes in the small intestine include atrophy of the muscle and mucosal surfaces, thinning of the villi, and a decrease in epithelial cells. This results in some decrease in the absorption of fats and vitamin B₁₂. A number of disorders may cause malabsorption, including infection, small intestine diverticuli (small dilations or pockets leading off the tract), pancreatic insufficiency, celiac disease, and mental disorders such as dementia. Elderly patients with malabsorption are undernourished, weak, and debilitated. Nursing management includes disease-specific treatment and appropriate nutrition (Timiras, 2007).

Large Intestine

The main function of the large intestine is storage, propulsion, and evacuation of feces. Age-related changes in the large intestine include atrophy of the mucosa, proliferation of connective tissue, and vascular changes, of which most are atherosclerotic. The tone of the internal anal sphincter decreases, which may lead to incontinence or incomplete emptying of the bowel. Nerve impulses that usually indicate the need to defecate may be diminished. This may account for the increased incidence of constipation (Lewis et al, 2007). In addition, the incidence of diverticuli is increased in the elderly. Diverticuli are prevalent in 30% to 40% of people older than 50 years (Timiras, 2007).

Gallbladder

The gallbladder and bile ducts are unaffected by aging. However, the incidence of gallstones does increase with age. Bile may become more lithogenic with advancing age, possibly because of an increase in biliary cholesterol related to diet and hormonal changes that affect cholesterol metabolism. The bile salt pool also decreases as a result of a decrease in bile salt synthesis. These predispositions for stone development, along with a tendency for dehydration in older adults, explain the increased incidence of cholelithiasis and cholecystitis in older adults. The complications of cholelithiasis in older adults include empyema, perforation, and choledocholithiasis (calculi in the common bile duct). These complications are often seen in persons older than age 65 and those with diabetes (Lewis et al, 2007).

Pancreas

The pancreas shows some age-related changes, such as fibrosis, fatty acid deposits, and atrophy, but the size is not affected (Lewis et al, 2007). However, the volume of pancreatic secretions declines after the age of 40, and enzyme output diminishes with advancing age. This decrease in enzyme activity affects the digestion of fats and may account for a vague intolerance of fatty foods in older adults. There is an increased incidence of pancreatic cancer and pancreatitis in older adults.

Liver

The liver is a sturdy organ and retains most of its functions throughout the life span. Although the liver size decreases after age 50, liver function tests may remain within normal limits. A decline in cardiac output associated with aging contributes to a decrease in hepatic blood flow. As hepatic blood flow slows, drug metabolism is reduced, which leaves the aging liver more susceptible to drugs and toxins. Elderly persons have a decreased ability to compensate for infectious, immunologic, and metabolic disorders (Lewis et al, 2007). Some evidence suggests that normal aging may adversely affect liver tissue regeneration. The mechanism of this effect is not fully known, but it may be a result of a generalized slowing of repair or an inadequate response to regeneration of liver tissue.

Nausea and Vomiting

Vomiting is controlled through a central vomiting center in the medulla. This center is close to the pain and respiratory centers; it is also near the centers that control vestibular and vasomotor function. Occasionally stimuli from one center spill over to another, and symptoms may become mixed. No distinct nausea center exists; however, the symptom of nausea may result from early stimulation of the vomiting center (Fig. 26–1).

Nausea may be difficult for clients to describe; many use the phrase “I feel sick” to convey the symptom of nausea. It is important to keep in mind that although nausea usually precedes vomiting, it may also be a freestanding symptom. In general, nausea in the absence of vomiting is of central, rather than peripheral, origin (i.e., the symptom is initiated centrally in the brain rather than peripherally in the GI tract). Central nausea is usually a response to a metabolic disorder.

It is important to obtain a detailed description of events surrounding a complaint of nausea and vomiting. Data should be elicited about precipitating factors (e.g., the relationship of nausea and vomiting to food intake, medications, and activity). The client should be questioned about the presence of nausea and vomiting, as well as diarrhea or constipation. It is important to obtain information about the amount and characteristics of the emesis and whether the vomitus contained food particles, bile, or blood (bright red or the color of coffee grounds). Other symptoms such as a fever, sweating, pallor, dizziness, and pain should be determined. Because older adults are at particular risk for dehydration and electrolyte imbalances, it is essential to establish the frequency and amount of emesis and to examine clients for signs and symptoms of fluid and electrolyte imbalances.

Nursing interventions include many self-help measures, including dietary changes such as drinking clear liquids, progressing from eating bland foods to solid foods, and small frequent feedings. If vomiting occurs, fluid replacement should be a priority. Sips of fluids every 15 minutes until more can be tolerated may decrease episodes of dehydration. Older adults are at high risk for aspiration, and they should be placed in a semi-Fowler’s or side-lying position when drinking liquids. It is important that older adults be made aware of the signs and symptoms of dehydration and electrolyte imbalances, as well as when to seek medical care. Any episodes of prolonged nausea or vomiting require careful evaluation by a health care provider. In addition, it should be made clear that pharmacologic therapy used to treat nausea and vomiting can cause sedation, confusion, and delirium in the older adult.

Anorexia

Anorexia as a symptom should not be confused with anorexia nervosa, which is an eating disorder of psychiatric significance. The term anorexia literally means “lack of appetite.” Hunger and appetite are not synonymous; hunger is related to the physiologic need for food. It is important for the nurse to ascertain whether the decreased food intake is truly because of a loss of appetite. Once that is determined, the nurse must ask questions regarding other symptoms, including weight loss, nausea, vomiting, abdominal pain, diarrhea, and constipation. In addition, psychosocial factors such as stress, grief, pain, and concomitant illnesses may also need to be assessed. Older adults are often faced with limited financial resources. This may result in them purchasing less fresh fruits and vegetables and may limit their overall ability to purchase enough food (Lewis et al, 2007).

Nursing interventions for older clients with anorexia include monitoring of intake, output, and weight. It is important to acknowledge a client’s symptoms and provide gentle encouragement for him or her to eat for nutritional purposes. Small, frequent feedings may be helpful. Encouraging older clients to seek medical attention for anorexia is also important because clients may not be aware of the problem.

Abdominal Pain

The symptom of abdominal pain is often difficult to fully assess. With older adults, it can be even more difficult, even for a skilled clinician. The assessment of pain can be made easier by thinking in terms of the three pathways for pain impulses. The first type are the visceral pain pathways, which are activated by receptors in the wall of the abdominal viscera and develop from stretching or distending the abdominal wall or from inflammation. This pain is often diffuse, is poorly localized, and has a gnawing, burning, or cramping quality. The second type are somatic or parietal pathways, which are activated by receptors in the parietal peritoneum and other supporting tissues. This type of pain is usually sharp, more intense, constant, and better localized than visceral pain. The third type are referral pathways, which account for referred pain (i.e., pain felt at a different site than the source of the pain but sharing the same dermatome). This pain is usually sharp and well localized; it may resemble somatic pain (Fig. 26–2).

In assessing any type of pain, the nurse should elicit information about its duration, location, mode of onset (sudden or gradual), intensity, quality, rhythm, relationship to food, alleviating and aggravating factors, and radiation (e.g., back, neck, or groin), as well as the older client’s ability to pass stool and gas. Elderly persons may complain of vague symptoms and wait much longer than their younger counterparts to seek medical care. The elderly are also less likely to exhibit leukocytosis (an increased white blood cell count), fevers, rebound tenderness, or local rigidity (Tazkarji, 2008).

Nursing interventions include measures to increase comfort and pain relief. Again, the nurse should encourage older clients to see their health care provider for a complete evaluation of the abdominal pain. Abdominal pain that is severe is often known as an acute abdomen. Nursing procedures commonly done for an acute abdomen include (1) starting intravenous fluids as ordered, (2) placing a nasogastric tube for decompression of the stomach, (3) monitoring and recording vital signs and reporting abnormal findings, (4) monitoring intake and output frequently and recording accurate amounts hourly, and (5) completing an assessment on the onset of pain, presence of vomiting or diarrhea, presence of fever, and an accurate medical and surgical history.

Gas

Complaints come in the form of belching, bloating, fullness, and flatus. About 99% of the gas present in the GI tract of adults comprises five gases: nitrogen, oxygen, hydrogen, carbon dioxide, and methane. The percentage of each individual gas depends on the source; these sources include swallowing, diffusion of gas from the bloodstream to the intestinal lumen, and processing of food. All these gases are odorless; the unpleasant odor associated with flatus is probably a result of hydrogen sulfide that is metabolized from sulfur-containing foods. A frequency of 7 to 20 gas passages a day is considered normal. Intestinal gas is frequently accompanied by intense abdominal pain, which may be relieved by repositioning or walking.

Although belching primarily comes from the unconscious swallowing of air, it is important to assess clients for other symptoms suggestive of gastritis or PUD. Many complaints of bloating and fullness are related to a motility disorder or malabsorption, but in older adults the complaints must be taken more seriously. Further assessment is required, such as questioning about changes in bowel function, pain, and other GI tract symptoms.

Although the expulsion of flatus is a normal event, excessive flatus may have several causes. Some clients form more gas within the gut, some swallow more air, and others may have excessive flatus because of the nature of the foods consumed. Common culprits include beans, cabbage, legumes, raisins, and artificial sweeteners. In addition, clients who are lactose intolerant may produce more gas. Careful questioning may reveal one or a combination of these causes.

Nursing interventions focus on client education about the cause and nature of intestinal gas. The keys to treatment are changes in dietary factors (e.g., focusing on eating more slowly and avoiding gas-producing foods) and a routine exercise plan.

Diarrhea

Diarrhea is an increase in the frequency of stools, but many definitions also include a change in consistency (e.g., watery stools). Diarrhea may be due to increased bowel motility or interference in the normal absorption of water and nutrients in the bowel. When an older client complains of diarrhea, it is important to ascertain exactly what is meant. In addition, the description of the diarrhea may be useless unless a client’s normal bowel habits are known.

The nurse should ask about precipitating events (e.g., travel out of the country or eating at a restaurant), timing (intermittent or continuous), associated factors (fever, weight loss, abdominal pain, vomiting, dietary or medication changes, and any systemic diseases), characteristics of the diarrhea (frequency, consistency, volume, foul smell, presence of mucus or blood, incontinence, awakening from sleep [e.g., nocturnal diarrhea usually points to an organic cause rather than a functional or infectious cause]), and whether the onset was sudden. All these questions help assess the diarrhea further to aid in determining the cause.

Nursing care focuses on maintaining adequate fluid and electrolyte balance, assessing for complications, and providing emotional support as necessary. Usual water loss in stools is 150 mL/day; severe diarrhea can account for up to 5 to 10 L of water loss daily. Therefore, assessing for signs and symptoms of dehydration and volume depletion in older clients is important. Clients and their families need to learn to report complications such as increased thirst, weakness, dizziness, palpitations, and fatigue. If fluid and electrolyte imbalances occur, either oral or parenteral treatment may be required because diarrhea in older adults can be life threatening. Nursing interventions should also be aimed at identifying and correcting the cause. Administration of antibiotics may be necessary for infectious diarrhea. Depending on the causative factor, antispasmodic and antidiarrheal medications may also be used. Education of clients and their families should include instruction on dietary changes: older clients with chronic diarrhea should avoid gas-forming foods, vegetables, spices, and milk products, and clients with acute diarrhea should consume bland foods, such as the BRAT (bananas, rice, applesauce, toast) diet and clear liquids.

Constipation

Constipation is a common problem among the elderly secondary to physiologic changes and is often a complication of polypharmacy. Among those older than 65, women are more often affected than men. Constipation is often defined according to the patient’s perception of abnormal bowel function (Berman, Brooks, & Silver, 2007). However, normal bowel patterns differ greatly among individuals. For example, a client may have the misperception that one bowel movement a day is necessary for good health.

Common causes of constipation in the elderly include diet (decreased fiber intake), mechanical obstruction (fecal impaction and cancer), medication side effects (aluminum- and calcium-based antacids, iron preparations, anticholinergics, narcotics, antidepressants, antipsychotics, and overuse of laxatives), multiple comorbidities, and mobility and functional issues (Ginsberg, Phillips, Wallace, & Josephson, 2007). Perhaps the most widespread cause of constipation in older adults is diet. It is usually a lack of certain foods, rather than the addition of certain foods, that leads to the problem. For example, many foods, such as fresh fruits and vegetables, contain natural laxatives, although older adults may have difficulty eating these foods because of dental problems. A second dietary cause of constipation is the lack of fiber or bulk and a decrease in fluid intake. In general, unrefined foods have more fiber than the refined foods that are popular in American society.

It is important to keep in mind that constipation can be a result of overuse or improper use of laxatives because of excessive concern about the frequency of bowel movements. In this instance, the nurse can reinforce with a client and his or her family that as long as the consistency is normal and the bowel movements occur at regular intervals, there is no reason to take laxatives.

Limitations on mobility can greatly affect the ability of an elderly person to self-feed and physically reach the toilet. They may feel awkward depending on others for these functions. Subsequently, they may ignore the urge to defecate rather than ask for help to get to the toilet. They may also decrease fluid intake in an effort to prevent urinary incontinence. These factors may greatly influence regular bowel patterns (Lewis et al, 2007).

Constipation is treated through dietary measures such as increasing fluid intake and increasing fiber, combined with light exercise and development of a regular toileting routine that includes responding to the urge to defecate. In teaching older adults about dietary changes, the nurse can instruct them that fiber need not be a “medicine;” it can be a “food.”

Multiple medications are available to treat constipation, and many of them are available over the counter. Laxatives are defined as drugs used to facilitate or stimulate the passage of feces and are classified as bulking agents (bran, psyllium), surfactants (stool softeners), emollients (mineral oil), contact stimulants (cascara, castor oil, bisacodyl), saline cathartics (magnesium hydroxide [Milk of Magnesia], citrate, sodium or potassium phosphate), and osmotic agents (lactulose, sorbitol). Laxatives may also be categorized by speed of action: group I drugs (castor oil, saline laxatives in high doses) act in 2 to 6 hours and produce watery stool; group II drugs (other contact stimulants, low-dose saline laxatives) act in 6 to 12 hours and produce a semi formed stool; and group III medications (bulking agents, surfactants, lactulose) produce soft stools in 1 to 3 days.

In addition to oral laxatives, several rectal agents are available. Enemas provide immediate relief but should be limited in their use for long-term treatment. Soapsud enemas should never be used because they lead to mucosal irritation. Small-volume enemas such as Fleets are the easiest to use. Rectal suppositories (bisacodyl, glycerin) may also be used, but they must be retained for 20 to 30 minutes for optimum results, and so may be more difficult for older clients to use.

Fecal Incontinence

Fecal incontinence, the involuntary passing of stool, may be acute or chronic, and it demands evaluation. For older adults the loss of bowel control is devastating and may significantly alter their quality of life. Fecal incontinence may be a result of colorectal lesions (perianal disease, proctitis, and tumors), neurologic problems (dementia, stroke, spinal cord lesions), laxative abuse, unrecognized lactose intolerance, diabetic neuropathy, poor dietary habits, or immobility (Kane, Ouslander, Abrass, & Resnick, 2009).

Nursing interventions focus on education concerning the prevention and treatment of incontinence in older adults. Examining the cause of the incontinence is important for the nurse, client, and family. Laxative abuse is completely preventable and treatable simply with education and reassurance to the client that one or two bowel movements a day are not necessary to be “regular.”

Regardless of the cause, a program of bowel control (see Client/Family Teaching Box) can usually help an elderly client who is aware of and distressed by incontinence. It is important to reassure older clients that control and retraining are achievable because many older adults believe that fecal incontinence is the first step on the road to permanent institutionalization. Other nursing interventions include methods to deal with the embarrassment of the incontinence, ways to decrease fecal odor, use of adult diapers, and skin care.

Gingivitis and Periodontitis

The gingivae, or gums, are subject to localized and systemic diseases, problems caused by drug therapy, poor oral hygiene, and poor nutrition. Gingivitis, an inflammation of the gums surrounding the teeth, may result in pain and bleeding; it can lead to periodontitis, a spreading of the inflammation to the underlying tissues, bones, or roots of the teeth. This is the most common reason for tooth loss with advancing age. Gingivitis resulting from overgrowth of the gingivae may occur in people taking phenytoin (Dilantin) on a long-term basis.

Candida albicans, or thrush, is an infection causing white lesions on the oral mucosa. It is often seen in persons with compromised immune systems and in those with suppressed immunity, such as individuals taking immunosuppressant drugs and antibiotics. The condition is most common in denture-bearing tissues of the mouth. The client may complain of an unpleasant taste, burning, or itching or may be asymptotic (Duthie, Katz, & Malone, 2007).

Diagnosis

The most common nursing diagnoses for an older client with gingivitis or periodontitis include

Planning and Expected Outcomes

An older adult must understand the relationship between oral health and overall health and well-being. The nurse must determine a client’s feelings and attitude about performing the self-care necessary to achieve the desired goals.

Expected outcomes for an older client with gingivitis or periodontitis include

Intervention

Nursing management of an older client with gingivitis or periodontitis includes promotion of regular oral hygiene, regular preventive dental care, and maintenance of nutritional status. In addition, assessing the client’s knowledge of the importance of oral hygiene and frequently reinforcing oral hygiene practices are important roles for the nurse. Oral hygiene includes flossing regularly, brushing teeth or dentures, and using saline mouth rinses as needed. Professional dental care should be sought routinely every 6 months or more often as needed. Proper fit of dentures initially and at all subsequent visits to both the dentist and the primary health care provider is also encouraged. Pain relief, which will facilitate adequate nutrition, can be managed by nonnarcotic pain medications (e.g., acetaminophen or aspirin), frequent mouth rinses, and a liquid or soft diet.

The key to treatment of gingivitis and periodontitis is prevention. Although good oral hygiene needs to begin early in life, it is never too late for an older client to begin routine dental care and oral hygiene. The nurse should discuss with the client the use of nutritional foods that are nonirritating, such as soft foods like pudding and custards, and the use of nutritional supplements like Ensure.

Evaluation

Evaluation includes documentation of achievement of the expected outcomes, establishment and maintenance of regular dental care and oral hygiene practices, and prevention of infection. Evaluation focuses on an older adult’s ability to carry out the recommendations and whether any changes in self-care have occurred as a result. Findings of an oral cavity inspection should be noted, as should any instructions or explanations given to the client. The client’s response to recommended treatment measures should also be documented.

Dysphagia

Dysphagia (difficult swallowing) is a common problem with increased prevalence in the elderly population. Weakened esophageal smooth muscle and incompetent sphincter function are contributory in the elderly who develop dysphagia. Dysphagia is a symptom with many underlying causes, including stroke, neurologic disease (Alzheimer’s disease), local trauma or tissue damage, and tumors that may obstruct the flow of food and liquids in the esophagus. Symptoms may range from mild to severe to a complete inability to swallow (Lewis et al, 2007).

Dysphagia may compromise the nutritional status in the older adult, increase the risk of aspiration pneumonia, and lead to a decreased quality of life.

Nursing care is aimed at ensuring the patient receives adequate nutrition, safe positioning during feeding to prevent aspiration, and thickening liquids to aid the person in swallowing. Occupational therapy with the aim of retraining the patient to swallow is often used in the care and rehabilitation of these older clients.

Diagnosis

Nursing diagnoses for an older client with dysphagia include

Planning and Expected Outcomes

It is essential to determine whether an older client is ready to learn the self-care measures necessary to reduce the symptoms. Determining the extent of a client’s specific fears created by learning of the palliative nature of interventions is important because the type and degree of fear affects the nurse’s specificity in intervention strategies.

Expected outcomes for an older client with dysphagia include

Intervention

Nursing management of an older client with dysphagia includes maintenance of hydration and nutritional status, prevention of aspiration, and provision of emotional support and information regarding the diagnosis and prognosis. Additionally, the nurse provides support and reassurance directed at a client’s fear of eating related to the pain, difficulty in swallowing, and frequent regurgitation. Optimizing nutritional status and preventing weight loss are important because fear of eating may lead to chronic weight loss. Instruction regarding eating habits and maintaining weight and nutrition is important. For example, small, frequent meals, pureed or soft foods, and high-protein, high-calorie foods are helpful. The nurse should instruct the client to elevate the head of the bed to prevent nocturnal aspiration.

Evaluation

Evaluation includes documentation of achievement of the expected outcomes, prevention of aspiration, and maintenance of nutrition. Evaluation of how the client is coping with the diagnosis may be assessed through a client’s resumption of activities and ability to verbalize feelings. Additionally, evaluation focuses on a client’s ability to satisfactorily incorporate and adhere to the dietary recommendations and modify behaviors and lifestyle to reduce symptoms.

Gastroesophageal Reflux and Esophagitis

Gastroesophageal reflux is a prevalent condition in the elderly, found in 20% to 50% of the geriatric population. Causes are diminished esophageal peristalsis, poor clearance of gastric acid, esophageal injury, and a decrease in salivary secretions. The elderly also take medications that can decrease esophageal sphincter pressures. Examples of medications that may induce esophageal injury include tetracycline, alendronate, potassium chloride, quinidine, aspirin, ascorbic acid, nonsteroidal antiinflammatory drugs (NSAIDs), clindamycin, and theophylline. The elderly often take medications lying down, pills may be too large causing injury to the esophagus, and inadequate fluids may be taken with medications and worsen symptoms (Wolfe, 2006).

Esophagitis is simply an inflammation of the esophagus. Most often this results from gastroesophageal reflux caused by either prolonged vomiting or an incompetent lower esophageal sphincter. The amount of mucosal damage is related to the contact time between the esophageal mucosa and the gastric contents, as well as the acidity and quantity of gastric secretions.

Hydrochloric acid from the stomach alters the pH of the esophagus and allows mucosal protein to be denatured. The pepsin in gastric secretions has proteolytic properties that are enhanced when the pH is around 2.0. The combination of pepsin and hydrochloric acid increases the possibility of damage. Reflux has been shown to cause an inflammation that penetrates to the muscularis layer, which results in motor dysfunction and decreased esophageal clearance. The end results are increased esophageal contact time, more muscle damage, and increased amounts of reflux.

Symptoms include heartburn, retrosternal discomfort, and the regurgitation of sour, bitter material. Symptoms are often precipitated by the ingestion of a large amount of fatty or spicy foods or alcohol. Strictures may develop that make food passage difficult. Dysphagia for both liquids and solids increases when severe obstruction occurs. If regurgitation occurs often, substernal pain may result, occasionally mimicking a heart attack. Reflux may be aggravated by postural changes, such as lying supine when sleeping, but may occur in any position. Pulmonary aspiration as a result of reflux is common, when severe; it may lead to pneumonia.

Hiatal Hernia

A hiatal hernia (diaphragmatic or esophageal hernia) is a major cause of reflux and esophagitis and occurs when part of the stomach protrudes through an opening of the diaphragm (Fig. 26–3). The condition may he intermittent or continuous. The continuous type is least common, accounting for only about 10% of cases. Either part or all of the stomach, and even the intestines, may herniate, causing dyspepsia, severe pain, and often a gastric ulceration. The intermittent type, or sliding hernia, occurs with changes in position or with increased peristalsis. The stomach is forced through the opening of the diaphragm when the person is prone and moves back to its normal position when the person stands up. Most hiatal hernias are asymptomatic and require no treatment. Symptoms, when they arise, include heartburn, gastric regurgitation, dysphagia, and indigestion. These symptoms are accentuated (1) when in the supine position after meals, (2) after overeating, (3) after physical exertion, or (4) with a sudden change in posture (Lewis et al, 2007).

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