Transcript REFLUX and Dysphagia - Jan

A BURNING ISSUE
Maureen Hounslow Specialist Dysphagia Nurse ALD
What is Dysphagia
 Any difficulty swallowing.
Stages of Dysphagia
 Oral – anatomy -open mouth swallow ? -High
Dysphagia
 Pharyngeal – residue/movement /sensation -High
Dysphagia
 Oesophageal –-Low Dysphagia
Under-recognised and undereported
The Normal Swallow
What Can Go Wrong ?
 Difficulty chewing/moving keeping food in the mouth
 Excess/reduced saliva
 Muscle weakness/stiffness in face and neck
 Changes in sensation
 Changes to the Swallow reflex
Gastro oesophageal reflux disease
(GORD)
Acid from the stomach leaks into the oesophagus
 Common terms
 Reflux
 Heartburn –burning pain -upper chest
 Indigestion - discomfort -lower abdomen
 Laryngo-pharyngeal reflux –where stomach acid
travels into the throat
Reflux and people with learning
disability
Prevalence higher in people with a learning
disability(LD) –with severe and profound LD.
Poly pharmacy, scoliosis/Kyphosis, obesity,poor diet.
 Helicobacter pylori, a class 1 carcinogen linked to
stomach cancer, gastric ulcer
 High prevalence of oesophageal stage cancers in LD
48%-59% vs 25% of general population cancer deaths.
Causes of Reflux
 Band of muscle/sphincter at bottom of oesophagus does not work
well
 Pressure in stomach increases to more than sphincter can withstand.
 Side effect of medications.
Anti-inflamatories and painkillers,
Anticonvulsants, psychotropics, muscle relaxants E.g. diazepam,
Baclofen,
Taking tablets with water -getting stuck (Oesophagitis)
 Other medical conditions eg Hiatius hernia/helicobacter pylori
Symptoms of reflux
 Feelings of reflux
-Heartburn burning pain/feeling rises from lower chest up towards the neck.
-Sore throat
-Pain after meals and after hot drinks.
 A feeling of a lump in the throat.(globus)
 Feeling sick, an acid taste in the mouth, bloating,
 Post nasal drip –normal mucus drips down back of the throat -irritated mucosa
and tissue.(Hypersensitive)
Silent reflux –maybe no symptoms
Signs/Observations of Reflux
 Irritable “barking” Cough worse at night
 Throat clearing
 Breathing difficulties – newly diagnosed with asthma –Chronic obstructive
pulmonary disease (COPD). Noisy breathing
 Belching,
 Excess saliva
 Gum/teeth problems
 Bad breath
 Hoarse voice/wet voice -mucus in the throat
 Trouble swallowing/choking -sensation or event
Investigations
 Treatment on reported signs and symptoms
 Barium swallow –check motility and ? anatomical problems
 Oesophago-gastro duodenoscopy (OGD) –gastroscopy or
endoscopy/flexible endoscopy by ENT -check vocal cords and
anatomy
 Hiatius hernia.
helicobacter pylori –
 24 hour PH monitoring
Patients` story
 Referral – Lady 60 years, coughs when eating and drinking.
 Diagnosis -Cerebral palsy, learning disability,
Hypertension, Hypothyroid.
 Reported -Just want the cough to stop unable to sleep,
“Little accidents” - “No ones listening” “will have a heart
attack”, “am scared of choking”
 Observed breathless and wheezy.
 Verbal communication –? Limited comprehension.
Difficulty communicating health needs.
Behaviour and lifestyle
 Obese BMI 33kg2 (31-40) healthy range = 18-25
overweight = 26 -30
 Wanted “to diet “ - chose a poor diet and food choices.
 Lack of exercise -uses electric wheelchair.
Interventions
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Frequent course of antibiotics
A number of chest X-Rays
Rx asthma inhalers
Referral to respiratory nurse
 Referred to Dysphagia team for adults with a learning
disability (DTALD)
 Food choices/changes made,
 Easy Read Information/training sessions
 VF/barium meal
1 year on
 Fed up is just getting worse “is really bad now”
Pain, discomfort, feeling full, hoarse voice
 Non compliance with medications
 Deteriorating relationships with carers –screaming
arguments.
 Antidepressants Rx
 Endoscopy
Stage 4 Oesophagitis with Hiatius Hernia
Treatment
 Lansoprazole 30mg twice daily -Inhibitor
 Administered 30 minutes prior to eating.
Gaviscon advance –raft after meals
Motility medications after meals
 No food and limited sips of drink 2 hours before lying down at
night.
 To lay in a semi upright position at night –.
How is Reflux Treated ?
 Changing habits/lifestyle choices
 Medications
 Surgery
Habits/Lifestyle choices
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Stopping smoking
Avoid fried foods and high fat foods
Avoid Citrus, acidic fizzy drinks and alcohol
Avoid peppermint, tomatoes, chocolate, spicy foods, hot
drinks, caffeine. - Exacerbates reflux
Avoid large-meals
Weight loss.
Not wearing tight clothing/belts/lapstraps slipping
Not eating for approx 2-3 hours before bed.
Remain upright for a time after eating
Raise head of bed.
Avoid bending over
Medical Treatment
 Antacids -neutralise acid/coats eg Gaviscon
 Reflux suppressant eg Gaviscon Advance/Peptac builds the
raft.
 Proton pump inhibitor Acid blocking/ stops production -
eg lansoprazole/omeprazole/Ranitidine.
 Pro Kinetic medications -Motility medications –
metoclopramide/Domperidone
 Surgery
Surgical intervention
 Stricture - Dilation
 Fundoplication -Wrap and sew top of the stomach
around the lower part of the oesophagus.
 Lynx band a ring of placed around the outside of the
lower oesophagus. strengthens the valve.
Complications of reflux
 Change in quality of life, Mood/ behaviour changes.
 Choking, aspiration, chest infections, food/drink
medication refusal
 Scarring and narrowing (stricture). long-standing
inflammation can cause a stricture of the oesophagus.
 Barrets oesophagus -Cells lining the oesophagus become
changed by acid.
 Cancer. The changed cells may become cancerous
Contact details
 Dysphagia team for adults with a learning disability
Team members
 Speech and Language Therapist
 Dietitian
 Specialist Dysphagia Nurse ALD Maureen Hounslow
 [email protected]