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Chapter 7: Digestive System Conditions: Introduction. Trace a piece of food through the GI tract (Fig. 7.1) : Mouth (teeth, tongue, saliva) Esophagus, lower esophageal valve Stomach, pyloric valve Small intestine Duodenum, jejunum, ileum, ileocecal valve Large intestine

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Chapter 7 digestive system conditions introduction l.jpg
Chapter 7: Digestive System Conditions: Introduction

  • Trace a piece of food through the GI tract (Fig. 7.1) :

    • Mouth (teeth, tongue, saliva)

    • Esophagus, lower esophageal valve

    • Stomach, pyloric valve

    • Small intestine

      • Duodenum, jejunum, ileum, ileocecal valve

    • Large intestine

      • Cecum, ascending, transverse, descending, sigmoid colon

    • Rectum

    • Anus


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Chapter 7: Digestive System Conditions: Introduction

  • Accessory organs:

    • Liver

      • Bile, filter, blood proteins, clotting factors, anticoagulants…

    • Gallbladder

      • Stores, concentrates bile, releases into small intestine

    • Pancreas

      • Pancreatic juice, released into small intestine

  • GI problems and massage:

    • Common, non-dangerous problems can share symptoms with very dangerous problems; massage can give temporary relief, delaying an accurate diagnosis

    • Any problem in a new pattern that persists for more than 2–3 weeks should be pursued with a primary care provider


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Celiac Disease

  • Villi in small intestine are damaged because of gluten sensitivity

    • Also called celiac sprue, nontropical sprue, gluten-sensitive enteropathy

  • Incidence:

    • Diagnosed in 1:4,300

    • May be present (mild forms) in 1:133

    • Strong genetic link


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Celiac Disease, cont.

  • Autoimmune or allergic reaction to gluten

    • Gluten breaks down into gliadin; gliadin is absorbed into villi, causing inflammatory response

    • Villi degenerate, limiting access to all nutrients

    • Occurs often with other autoimmune diseases:

      • Rheumatoid arthritis, type 1 diabetes, thyroid disorders


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Celiac Disease, cont.

  • Signs and symptoms:

    • Malabsorption of nutrients:

      • GI pain, bloating, gas, diarrhea

      • Evidence of nutritional deficiency

    • Symptoms can be severe or subtle

  • Complications:

    • Anemia; folic acid deficiency (birth defects in babies); osteomalacia, osteoporosis; muscle spasms; failure to thrive; risk of seizures, CNS dysfunction with B12 deficiency

    • Chronic irritation can lead to cancer in GI tract; higher risk of non-Hodgkin’s lymphoma


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Celiac Disease, cont.

  • Diagnosis:

    • Blood test, tissue biopsy

    • Mild cases can resemble…

      • Irritable bowel syndrome, general indigestion, Crohn disease, ulcerative colitis, chronic fatigue syndrome, depression…

  • Treatment:

    • Avoid gluten in any form

      • This can be a challenge!


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Celiac Disease, cont.

  • Massage?

    • Has no impact on the disease, may relieve symptoms temporarily

      • If client knows s/he has celiac disease, this is appropriate

      • If client has symptoms without diagnosis, s/he needs to seek medical care—not just massage


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Crohn Disease

  • Progressive patchy areas of inflammation, all through the GI tract

  • Incidence:

    • Approximately 500,000 in the United States

    • Men = women; average age at onset is 27 years

    • Most common in United States, Canada, Scandinavia

    • Caucasians > other groups, 4:1

    • Genetic component: increased incidence within families


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Crohn Disease, cont.

  • Patchy inflamed regions (Fig. 7.2)

    • Often starts at the ileum, can affect anywhere in the GI tract

    • Inflammation can lead to ulcers, perforation, stenosis, fistulae

  • Causes:

    • Most consider it idiopathic

      • Exposure to paratuberculosis mycobacterium?

      • Stress, food triggers

      • High levels of certain cytokines


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Crohn Disease, cont.

  • Signs and symptoms:

    • Goes in flare and remission

      • During remission it may be silent

      • During flare: GI pain, cramping, diarrhea (with blood), bloating, weight loss, fever, joint pain, ulcers in mouth and throat, lesions on skin, anal fissures…


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Crohn Disease, cont.

  • Complications:

    • In children: impaired growth, delayed development

    • Abscesses, perforations, risk of peritonitis

    • Bowel obstructions

    • Fistulae drain bowel contents into other hollow organs (uterus, bladder)

    • Risk of colon cancer

    • Blocked ducts can lead to cirrhosis, jaundice

    • Lesions on legs, ankles


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Crohn Disease, cont.

  • Treatment:

    • Steroidal anti-inflammatories, immunosuppressant drugs to limit inflammation

    • Surgery to remove damaged tissue (usually has to be repeated)

    • Early, aggressive course of antibiotics (?)

    • Careful eating (liquid or even IV diet during flare)

  • Massage?

    • Avoid during flares—or energetic work only

    • During remission bodywork may be good coping strategy; improves intestinal function


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Esophageal Cancer

  • Malignant cells in esophagus

    • Proximal is squamous cell carcinoma (SCC)

    • Distal is adenocarcinoma

  • Incidence:

    • African American men have most SCC

    • Caucasian men have most adenocarcinoma

    • Men > women, 8:1

    • 13,500 diagnoses/year; 12,500 deaths

    • 5-year survival < 5%


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Esophageal Cancer, cont.

  • SCC: affects squamous epithelium of proximal and middle esophagus

    • Related to smoking, drinking, both together

    • Used to be the most common type of esophageal cancer

  • Adenocarcinoma: affects distal portion of esophagus

    • Usually begins as Barrett’s esophagus, a complication of GERD

    • Now more common than SCC


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Esophageal Cancer, cont.

  • Metastasis:

    • Directly to nearby structures:

      • Trachea, diaphragm, aorta, vena cava

    • Through lymphatics:

      • Lungs, liver, bones

    • Through blood:

      • Uncommon


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Esophageal Cancer, cont.

  • Risk factors:

    • Age, gender race (uncontrollable)

    • Tobacco, alcohol use (for SCC)

    • GERD, Barrett’s esophagus (for adenocarcinoma)

    • Other: exposure to poisons, radiation; hot beverages, vitamin deficiencies


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Esophageal Cancer, cont.

  • Signs and symptoms:

    • Early: none; often not palpable until after metastasis

    • Later: mechanical obstruction, dysphagia, coughing, sometimes with blood

  • Staging:

    • Based on depth of infiltration, involvement of lymph nodes, and presence of distant tumors


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Esophageal Cancer, cont.

  • Treatment:

    • Surgery, chemotherapy, radiation, photodynamic therapy…

    • Recovery is complicated by difficulties in eating

  • Massage?

    • Weigh benefits and risks according to the treatment options the client pursues;

    • Work with health care team for best benefit (improved sleep, better eating, immune system resilience, parasympathetic effect) and minimal risks


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Gastroenteritis

  • Inflammation of the stomach or small intestine

  • Incidence:

    • 100 million cases/year? (estimates)

    • Approximately 10% seek medical attention

    • 200,000 hospitalizations of children/year

    • 10,000 deaths/year


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Gastroenteritis, cont.

  • Causes:

    • Viruses: Norwalk, rotaviruses, hepatitis, enteroviruses; highly contagious; 50%–70% of all cases (Not flu!)

    • Bacteria: Salmonella, Shigella, Campylobacter, E. coli; contaminated food, water, ice

    • Bacterial or viral gastroenteritis is sometimes called “stomach flu”

    • Others: Giardia, cryptosporidium, candidiasis, toxins, allergies, other GI disorders (Crohn disease, celiac disease, irritable bowel syndrome, etc.


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Gastroenteritis, cont.

  • Signs and symptoms:

    • When lining of GI tract is inflamed, it cannot function: nausea, vomiting, diarrhea

  • Complications:

    • Dehydration: leading cause of death from gastroenteritis

    • Others: Guillain-Barré syndrome, meningitis, renal failure


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Gastroenteritis, cont.

  • Diagnosis:

    • Problematic: time and expense, some pathogens outlive symptoms

  • Treatment:

    • Often just fluids and rest, electrolyte replacement, good hygiene

    • Antibiotics exacerbate symptoms, anti-diarrhea medications interfere with shedding mechanism


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Gastroenteritis, cont.

  • Prognosis:

    • Most clear up within 2–3 days

    • Long-lasting cases indicate underlying pathologic condition

  • Massage?

    • Not during acute infection

    • In chronic situations, gather information about underlying causes; massage may offer symptomatic relief


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Gastroesophageal Reflux Disease (GERD)

  • Damage to lining of the esophagus due to reflux of stomach contents (Fig. 7.3)

  • Incidence

    • Begins as heartburn;

      • 7%–10% in United States have heartburn daily

      • 40% have heart burn once/month

    • Can happen at any age; most common in mature people


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Gastroesophageal Reflux Disease (GERD), cont.

  • Mostly related to dysfunctional lower esophageal sphincter (LES):

    • LES is too relaxed

    • LES does not allow clearing of esophagus

    • Low motility in stomach puts back-pressure on LES


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Gastroesophageal Reflux Disease (GERD), cont.

  • Complications:

    • Respiratory injury (gastric contents are inhaled)

    • Ulcers in esophagus

    • Stricture

    • Barrett’s esophagus, risk of esophageal cancer


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Gastroesophageal Reflux Disease (GERD), cont.

  • Risk Factors:

    • Pregnancy

    • Obesity

    • Smoking

    • Diet (fatty, acidic or spicy foods, caffeine…)

    • Connective tissue diseases (lupus, scleroderma)

    • Hiatal hernia

    • Delayed stomach emptying (diabetes, paralysis)

    • Others: radiation exposure, tumors, infection, some medications


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Gastroesophageal Reflux Disease (GERD), cont.

  • Signs and symptoms:

    • Heartburn, bloating, pain

      • Can mimic heart attack

    • Dysphagia, coughing, wheezing

    • Symptoms exacerbated by lying down

  • Treatment:

    • Management, repair

      • Change eating habits

      • Medication to reduce acidity, increase motility of stomach

      • Surgery to repair LES


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Gastroesophageal Reflux Disease (GERD), cont.

  • Massage?

    • Standard massage may exacerbate symptoms:

      • Increasing GI activity

      • Client lying down

    • Make adjustments for client comfort:

      • Schedule around eating

      • Work on chair, semi-reclined, with head elevated

      • Avoid abdomen if necessary


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Stomach Cancer

  • Malignant tumors in stomach

  • Incidence:

    • 24,000 diagnoses/year United States

    • 14,000 deaths/year

    • Most 60–80 years old

    • Men > women, 2:1


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Stomach Cancer, cont.

  • Most cases are adenocarcinomas

    • May be related to high intake of salted, pickled, smoked foods (began to decline in United States after introduction of refrigeration)

    • Related to infection with Helicobacter pylori

    • Incompletely broken-down food may become carcinogenic; poor motility increases risk

    • Undetectable in early stages; spreads to other abdominal organs directly, or liver through portal system


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Stomach Cancer, cont.

  • Risk Factors:

    • H. pylori infection

    • Diet: salted, smoked, pickled foods, nitrates

    • Tobacco, alcohol use

    • Other: previous stomach surgery, type A blood, age, gender, genes associated with colorectal cancer


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Stomach Cancer, cont.

  • Signs and symptoms:

    • Develop only after tumor is large enough to obstruct movement

      • Fullness, abdominal pain, weight loss, heartburn, ascites, blood in stool

  • Treatment:

    • Radiation, chemotherapy, surgery

    • 5-year survival rate approximately 20%


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Stomach Cancer, cont.

  • Massage?

    • Same guidelines as other clients with cancer:

      • Work with health care team to maximize benefits, minimize risks


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Ulcers

  • Tissue damage with impaired healing

    • Peptic ulcers of esophagus, stomach, small intestine have similar etiology to ulcers on the skin (Fig. 7.4)

  • Incidence:

    • 10% in the United States will have an ulcer at some time

    • 25 million in the United States have been diagnosed

    • 500,000–850,000 new diagnoses/year

    • 1 million hospitalizations

    • Men > women, 2:1


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Ulcers, cont.

  • Esophageal ulcers usually related to GERD

  • Gastric, duodenal ulcers usually related to a combination of factors:

    • Stress (moving in and out of stress, rather than being “stuck” there)

      • Aggressive vs. defensive mechanisms; aggressive mechanisms recover from stress faster than defensive ones

    • H. pylori infects most lesions (spirochete “drills” into stomach lining)

    • NSAIDs (specifically aspirin) damage stomach lining


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Ulcers, cont.

  • Signs and symptoms:

    • Gnawing, burning pain in abdomen

      • Relieved with antacids or eating

  • Complications:

    • Chronic bleeding can cause anemia

    • Perforation can lead to peritonitis

    • Stenosis can lead to obstruction

    • Risk of stomach cancer increased 2–6×

    • Also increased risk of lymphoma


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Ulcers, cont.

  • Treatment:

    • Antibiotics for H. pylori, bismuth, acid-reducers: 90% chance of full recovery

    • Surgery if necessary

      • Vagotomy, stomach surgery

  • Massage?

    • As long as client is comfortable, massage is appropriate

    • Be conservative in abdominal area


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Appendicitis

  • Inflammation, usually with infection, of vermiform appendix (suspended from cecum)

  • Incidence:

    • 1:1,000/year

    • Approximately 7% will eventually have appendicitis


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Appendicitis, cont.

  • Appendix is a hollow organ with some immune system function

    • When it is blocked, it can develop infection

      • Abscesses, perforation, rupture may lead to peritonitis

  • Signs and symptoms:

    • Extremely variable

      • Food aversion

      • Pain that settles in lower right quadrant

      • Rebound pain

      • Nausea, vomiting, fever

      • Pain on coughing, sneezing, abdominal movement


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Appendicitis, cont.

  • Complications:

    • Peritonitis

  • Diagnosis:

    • Still difficult; resembles gallstones, pancreatitis, Crohn disease, ulcerative colitis, diverticulitis, pelvic inflammatory disease, ectopic pregnancy…


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Appendicitis, cont.

  • Treatment:

    • Surgery, open or laparoscopic

      • Antibiotics are not usually permanently successful

  • Massage?

    • This is an emergency that requires medical attention

    • Postsurgical massage may be appropriate, with respect for pain and the risk of infection

    • Clients with a history of appendectomy are good candidates for massage


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Colorectal cancer

  • Development of tumors anywhere in large intestine or rectum

  • Incidence:

    • 135,000 diagnoses/year

    • 56,000 deaths/year

    • Most are >50 years old

    • Close to 6% in United States will eventually have colorectal cancer


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Colorectal Cancer, cont.

  • Most cases begin with adenomas: polyps somewhere in the bowel (Fig. 7.5)

    • Eventually, oncogenes are activated

    • Tumor-suppressor genes are inhibited

    • Cells replicate, infiltrate deeper layers of the colon (Fig. 7.6)

      • Metastasize through lymph system to brain, liver, lungs


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Colorectal Cancer, cont.

  • Causes:

    • 30%–40% of older Americans have polyps; the longer they are present, and the bigger they are, the higher the risk of cancer cells

      • High-fat foods linger in colon longer, become carcinogenic?

      • High-fiber diets “scrub” colon, reducing risk of lingering carcinogens?

      • Phytochemicals suppress malignant changes?


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Colorectal Cancer, cont.

  • Risk Factors:

    • Obesity

    • Genetics (colon cancer genes raise risk; only 5% of colon cancer patients have these genes)

    • Inflammatory bowel disease (Crohn disease and ulcerative colitis)

    • Age (over 50 years old)


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Colorectal Cancer, cont.

  • Signs and symptoms:

    • Constipation, narrowed stools, anemia from chronic blood loss

  • Diagnosis:

    • Digital rectal examination, fecal occult blood test, sigmoidoscopy, colonoscopy, CT scan


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Colorectal Cancer, cont.

  • Treatment:

    • Stage I or II: surgery to resect bowel

    • Stage III or IV: surgery, chemotherapy, radiation

  • Massage?

    • Same guidelines as for all cancer patients: work with health care team to maximize benefits, minimize risks

    • Clients with colostomy bags are good candidates for massage; locally avoid the bag and ask the client how to make him or her comfortable


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Diverticular Disease

  • Bulges in the small or large intestine (diverticulosis) that may become infected (diverticulitis) (Fig. 7.7)

  • Incidence:

    • Up to 50% of people 60–80 years of age have diverticula

    • Up to 66% of people over 85 have diverticula

    • Men = women


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Diverticular Disease, cont.

  • Bulges form during segmentation

    • Mucosa and submucosa herniate through muscularis to form small sacs: diverticula

    • Diverticula may collect fecal matter, bacteria

    • 20% of people with diverticulosis develop diverticulitis: infected diverticula

    • Mostly form in descending, sigmoid colon; can be anywhere in GI tract


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Diverticular Disease, cont.

  • Signs and symptoms:

    • Diverticulosis may be silent

    • Diverticulitis: pain, nausea, fever, cramping; slow or sudden onset

  • Complications:

    • Bleeding

    • Abscesses

    • Perforation

    • Blockage

    • Fistulae

    • Difficult to accurately screen for colorectal cancer


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Diverticular Disease, cont.

  • Treatment:

    • For diverticulosis: high-fiber diet, exercise to prevent future sacs from forming

    • For diverticulitis: antibiotics, controlled diet, surgery if necessary

  • Massage?

    • If the client knows s/he has diverticula but no infection, conduct deep abdominal work with special care: the colon is compromised and vulnerable to damage

    • Acute infection (diverticulitis) systemically contraindicates massage


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Irritable Bowel Syndrome (IBS)

  • Digestive system dysfunction with no structural changes

    • Also called spastic colon, irritable colon, mucus colitis, functional bowel syndrome

  • Incidence:

    • 20%–30% in the United States have IBS symptoms at some point

    • 5 million doctor visits/year

    • Women > men, 3:1


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Irritable Bowel Syndrome (IBS), cont.

  • Hyperreactive muscle tissue in colon

    • Peristalsis becomes uncoordinated

    • Dysfunction in “brain–gut axis”: feedback loop between sensory and motor neurons that control bowel function

    • Other smooth muscle anomalies:

      • Neurally mediated hypotension: seen with chronic fatigue syndrome

      • Well-established overlap between CFS, IBS, and fibromyalgia

    • Closely associated with emotional stress


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Irritable Bowel Syndrome (IBS), cont.

  • Signs and symptoms:

    • Pain, cramps, gas, bloating, alternating cycles of constipation and diarrhea

  • Diagnosis:

    • Ruling out other conditions

    • Colonoscopy shows no structural changes: only functional problems


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Irritable Bowel Syndrome (IBS), cont.

  • Treatment:

    • Look for triggers, avoid them

    • Coping strategies for stress

    • Add fiber, bulk to diet

    • Medications to help symptoms, anti-depressants

  • Massage?

    • If the client is comfortable, massage has many benefits, little risk:

      • Parasympathetic state, more efficient peristalsis, etc.

      • No structural changes, no risk of infection, perforation, structural damage


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Ulcerative Colitis

  • Progressive inflammation and ulceration of the colon

    • Part of “inflammatory bowel disease” (IBD) along with Crohn disease

  • Incidence:

    • Approximately 1 million in United States have IBD

    • Evenly split between Crohn disease and ulcerative colitis

    • Men = women

    • Most are 15–25 years old, or 55–65 years old at diagnosis


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Ulcerative Colitis, cont.

  • Most agree it is autoimmune attack on mucosa of colon

    • Flares and remission

    • Begins in rectum

    • Moves in continuous, connected affected area proximally up the colon (not patchy, like Crohn)


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Ulcerative Colitis, cont.

  • Signs and symptoms:

    • During flare:

      • Chronic diarrhea with blood and pus in stool

      • Cramping, loss of appetite, fever

    • May affect other tissues, systems:

      • Hepatitis, arthritis, osteoporosis, anemia, uveitis, kidney stones


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Ulcerative Colitis, cont.

  • Complications:

    • High risk of colorectal cancer

    • Toxic megacolon

  • Treatment:

    • Medications to limit severity

    • Steroidal anti-inflammatories, nicotine patches

    • Surgery to remove affected section of colon


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Ulcerative Colitis, cont.

  • Massage?

    • Deep abdominal work is contraindicated

      • Structural problems; colon is vulnerable to entrapment

      • During remission, massage may help to balance factors to reduce frequency of flares


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Cirrhosis

  • Healthy liver cells are replaced with scar tissue

    • Usually a result of some other disorder

  • Incidence:

    • Liver disease affects 25 million in the United States

    • 25,000–35,000 deaths/year

    • #8 cause of death in the United States


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Cirrhosis, cont.

  • Hepatocytes are highly organized, delicate cells

    • Chronic irritation (viral attack, toxic exposures) causes hepatocytes to die off, replaced with scar tissue (Fig. 7.8)

    • Channels are blocked; liver function is decreased

    • Bumpy appearance: “hobnailed liver”


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Cirrhosis, cont.

  • Causes:

    • Alcoholism, hepatitis C are major causes

      • Others include other forms of hepatitis, gallstones, environmental toxins, heart failure

  • Signs and symptoms:

    • Subtle in early stages (liver can compensate for lost function):

      • Nausea, vomiting, weight loss, red patches on skin

    • In later stages complications develop


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Cirrhosis, cont.

  • Complications:

    • Portal hypertension (back-up of fluid in portal system), leads to…

      • Splenomegaly, ascites (Fig. 7.9), internal varices

    • Bleeding, bruising (lack of clotting factors)

    • Muscle wasting

    • Jaundice

    • Systemic edema

    • Hormone disruption

    • Encephalopathy

    • Kidney failure


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Cirrhosis, cont.

  • Treatment:

    • Stop the damage!

    • Manage complications

    • Transplant, if necessary

      • 12,000 on waiting list; 5,300 performed/year

  • Massage?

    • Liver is a keystone for fluid management; advanced cirrhosis contraindicates circulatory massage

    • Get information about possible complications and cautions for bodywork

    • Noncirculatory massage may be safe and appropriate


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Gallstones

  • Formation of stones in gallbladder

    • Also called cholelithiasis

  • Incidence:

    • 20 million in the United States have been diagnosed with gallstones

    • 1%–3% have symptoms/year

    • Women > men, 2:1


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Gallstones, cont.

  • The gallbladder stores and concentrates bile, releases it into small intestine for emulsification of fats

    • When cholesterol or other substances accumulate in high concentration, tiny crystals (bile sludge) or larger stones may form


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Gallstones, cont.

  • Contributing factors:

    • Obesity

    • Estrogen

    • Race, gender, age

    • Cholesterol-lowering drugs

    • Diabetes

    • Rapid weight loss

    • Fasting


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Gallstones, cont.

  • Signs and symptoms:

    • 80% are completely silent

    • Symptoms occur when stone is in duct (Fig. 7.10, 7.11)

      • Pain at right costal angle, refers between scapulae, right shoulder

  • Complications:

    • If a stone gets lodged, the duct is blocked

      • Jaundice, cirrhosis

      • Pancreatitis

    • Infection of gallbladder

      • Possible rupture and peritonitis


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Gallstones, cont.

  • Treatment:

    • Surgery to remove gallbladder

      • Usually laparoscopic

    • New procedures try to preserve gallbladder

    • Postsurgery, may have difficulty digesting fats

  • Massage?

    • Acute biliary colic requires medical attention, not massage

      • Refers to scapulae, right shoulder

    • Clients with a history of gallstones or gallbladder surgery and no present symptoms are fine for massage

      • If the client knows gallstones are present, avoid the right costal angle


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Hepatitis

  • Viral attack on the liver

    • Until late 70s: hepatitis A, hepatitis B, hepatitis non-A non-B

  • Now we have identified hepatitis A, B, C, D, E, F, G

  • 90% of infections are A, B, or C

    • Exposure to one gives no protection from others


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Hepatitis, cont.

  • Signs and symptoms:

    • Severity and duration of symptoms depends on type of infection

      • Malaise

      • Nausea

      • Fatigue

      • Jaundice


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Hepatitis A

  • Incidence:

    • 180,000 infections/year, 30% adults test positive for exposure

  • Pattern:

    • Most acute, shortest lasting (only by comparison; it still lasts several weeks)

    • 1 infection imparts immunity


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Hepatitis A, cont.

  • Communicability:

    • Spread through oral–fecal contamination

      • Water, shellfish, food workers

    • Also communicable through shared fluids

      • Needles, sexual activity

  • Treatment:

    • Rest, supportive therapy

    • Gamma globulin shot (“borrowed” antibodies)

    • Vaccine is available


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Hepatitis B

  • Incidence:

    • 200,000 new infections/year; mostly among newly sexually active teens and young adults

    • 1–1.25 million are chronic carriers

  • Pattern:

    • Less acute, but longer lasting (many months or years)

    • 5% become chronic carriers

      • High risk of liver disease: cirrhosis, liver failure, liver cancer


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Hepatitis B, cont.

  • Communicability:

    • Highly communicable in shared fluids—viral load is high so minimal contact is needed.

      • Very sturdy outside a host: 6 months at room temperature

      • Tattoo needles, acupuncture needles, drug needles, sexual activity, long-term close contact

  • Treatment:

    • Antiviral medication

    • Vaccine is available: required for some health care professions


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Hepatitis C

  • Incidence:

    • Currently carried by 4 million in United States

    • 3 million have it as a chronic infection

    • Most people were infected 1–3 decades ago

    • Causes 8–10,000 deaths/year

  • Pattern:

    • Symptoms don’t appear for many years after infection

    • 25% spontaneously recover; 75% have a high risk of liver disease

    • Rivals alcoholism for leading cause of cirrhosis

    • #1 reason for liver transplants


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Hepatitis C, cont.

  • Communicability:

    • Shared fluids

  • Treatment:

    • Antivirals (the sooner the better)

    • No vaccine is available


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Hepatitis, general

  • Massage for any type of hepatitis?

    • Fluid management problems contraindicate circulatory massage

      • Chronic hepatitis B or C may be safe, depending on health and resilience of the client—compare massage to activities of daily living

    • Energetic or reflexive techniques may be safe and appropriate

    • Get information about complications

    • Clients who have fully recovered from hepatitis infection are good candidates for massage


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Jaundice

  • Symptom of liver dysfunction

  • Bilirubin (by-product of RBC dismantling in the spleen) is an ingredient of bile

    • When the liver does not drain correctly (obstructed channels, ducts), bilirubin accumulates in the bloodstream, leading to discoloration of skin, eyes, mucous membranes


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Jaundice, cont.

  • Types of jaundice:

    • Neonatal jaundice:

      • Immature liver, spleen; treated with exposure to “bili-lights” to stimulate liver activity

    • Hemolytic jaundice:

      • Related to hemolytic anemia: premature death of RBCs

    • Hepatic jaundice:

      • Any problem that originates in the liver: cirrhosis, hepatitis, etc.

    • Extrahepatic jaundice:

      • Any obstruction of ducts that originates outside the liver: gallstones, tumors, pregnancy


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Jaundice, cont.

  • Signs and symptoms:

    • Accumulation of bilirubin in skin, mucous membranes:

      • Eyes, gums, skin become yellowish (Fig. 7.12)

      • Urine is dark

      • Feces are pale (bilirubin in urinary system, not digestive tract)


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Jaundice, cont.

  • Complications:

    • Poor secretion of bile means less access to fat-soluble vitamins, especially vitamin K (related to bleeding disorders)

  • Massage?

    • Depends on what causes the jaundice, what kind of care the client is getting, and the ability to manage fluid movement in the body

      • Generally this is an indication of a primary problem that contraindicates circulatory massage

      • It may indicate a potentially communicable infection

      • Work with health care team for best benefit, least risk


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Liver Cancer

  • Malignant cells that originate in the liver

    • Also called hepatocellular carcinoma

    • Not metastatic liver disease (metastasis from another location)

  • Incidence:

    • Worldwide fairly common

    • United States: 15,000 diagnoses/year, 15,000 deaths

    • Statistics expected to rise with maturation of hepatitis C patients

    • Men > women, 4:1 among some groups


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Liver Cancer, cont.

  • Hepatocytes replicate out of control

    • Related to history of cirrhosis, hepatitis, alcoholism

    • May form single or multiple tumors

      • Highly invested with blood vessels: high risk of metastasis


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Liver Cancer, cont.

  • Risk factors:

    • HBV, HCV infection

    • Alcoholism

    • Hemochromatosis

    • Cirrhosis

    • Aflatoxin B1 (toxin common in Asia, Sub-Saharan Africa)


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Liver Cancer, cont.

  • Signs and symptoms:

    • Similar to signs of hepatitis, cirrhosis, which are probably also present:

      • Nausea, food aversion, weight loss, ascites, muscle wasting, fever, jaundice

  • Diagnosis:

    • CT scan, ultrasound, MRI, biopsy

      • Important to distinguish between liver cancer and metastatic liver disease


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Liver Cancer, cont.

  • Staging:

    • Described by treatment option rather than progression:

      • Resectable vs. unresectable

  • Treatment:

    • Often not responsive to chemotherapy, radiation

    • Many patients not good candidates for open surgery

    • Closed surgery options in development

    • 5-year survival rate <10%


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Liver Cancer, cont.

  • Massage?

    • As with other cancers, work with health care team for best benefit, minimum risk

    • May improve tolerance of treatment

    • Comfort measure for dying person


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Pancreatic Cancer

  • Uncontrolled replication of pancreas cells

    • Usually in exocrine ducts

    • Sometimes in endocrine-producing cells

  • Incidence:

    • 30,000 diagnoses/year

    • 30,000 deaths/year

    • Life expectancy: 4–6 months post-diagnosis


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Pancreatic Cancer, cont.

  • Two types of pancreatic cancer:

    • Adenocarcinoma (tumor in exocrine ducts)

    • Neuroendocrine tumors (occur in islet cells)

    • Metastasis:

      • Through direct contact with other abdominal structures

      • Through lymphatics to the liver


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Pancreatic Cancer, cont.

  • Risk factors:

    • Age, gender, race

    • Smoking

    • Chronic pancreatitis

    • Diabetes

    • Diet

    • Colon cancer, breast cancer genes

    • History of melanoma


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Pancreatic Cancer, cont.

  • Signs and symptoms:

    • Usually too subtle to notice in early stages

      • Weight loss, abdominal discomfort, loss of appetite

      • Jaundice, ascites, other liver signs if duct is blocked

      • Blood glucose disruption if islet cells are affected

  • Diagnosis:

    • Difficult to get accurate diagnosis without risk of spreading cancer cells


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Pancreatic Cancer, cont.

  • Staging

    • Potentially resectable

    • Locally advanced

    • Metastatic

  • Treatment:

    • Surgery when possible, radiation, chemotherapy

      • May prolong life by several months; not usually curative

      • Surgery may be performed to correct blockages


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    Pancreatic Cancer, cont.

    • Massage?

      • As with other types of cancer, work with health care team for best benefit, minimum risk

      • May improve tolerance of treatment

      • Appropriate as comfort measure for dying person


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    Pancreatitis

    • Inflammation of the pancreas

      • Can be acute or chronic

    • Incidence

      • 50,000–80,000 diagnoses of acute pancreatitis/year

      • Unknown statistics for chronic pancreatitis; mostly related to alcoholism


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    Pancreatitis, cont.

    • Pancreatitis occurs when the pancreatic duct is blocked and the secretions damage the organ

      • Acute pancreatitis:

        • blunt trauma, gallstones, cystic fibrosis, exposure to alcohol or other toxins: sudden onset, medical emergency

      • Chronic pancreatitis:

        • permanent damage to gland; ducts are calcified; usually related to alcohol abuse


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    Pancreatitis, cont.

    • Signs and symptoms:

      • Upper abdominal pain

        • For acute: extreme, sudden onset

        • For chronic: may build to a crisis, then resolve until next episode; pain eventually becomes unremitting

      • Loss of pancreatic enzymes, hormones

      • Jaundice if common bile duct is blocked


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    Pancreatitis, cont.

    • Treatment:

      • Depends on cause

        • Removal of damaged tissue; open blocked ducts; supplement digestive enzymes; sever nerves if necessary

    • Massage?

      • Pancreas can refer pain to the back

        • Persistent pain in a new pattern should be referred to a primary care provider

      • Acute pancreatitis requires medical attention; chronic pancreatitis that is being treated may be appropriate within client comfort

      • A person with a history of pancreatitis but no current symptoms is a good candidate for massage


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    Candidiasis

    • Overgrowth of Candida albicans in digestive tract (Fig. 7.13)

    • Incidence:

      • Depends on the definition of the problem

        • Extreme version is most common in immune-suppressed population

        • Subtler version may be mistaken for allergies, hypothyroidism, other disorders


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    Candidiasis, cont.

    • Disruption in GI balance (with antibiotics, thymus tumors, hormonal imbalances) can lead to overgrowth of flora: candidiasis

    • Signs and symptoms:

      • Mouth lesions (thrush)

      • Anal lesions (like diaper rash)

      • Other skin lesions (affect nails, scalp too)

      • Systemic symptoms (acute): fever, chills

      • Systemic symptoms (chronic): food sensitivities, headache, chronic urinary tract infection, fatigue, etc…


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    Candidiasis, cont.

    • Diagnosis

      • Controversial: delineation between colonization and infestation is arbitrary

        • Acute cases: skin biopsy

        • Chronic cases: stool samples (expensive, time consuming)

    • Treatment:

      • Topical anti-fungals for skin problems

      • Internal anti-fungals for chronic problems

        • Reestablish balance between bacteria/yeasts (acidophilus)


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    Candidiasis, cont.

    • Massage?

      • For severe problems, get information on underlying problems (immune weakness, etc.)

      • For chronic problems, massage may be safe and appropriate


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    Peritonitis

    • Infection in the peritoneum

      • Dark, moist, 100°: a perfect growth medium! (Fig. 7.14)

    • How does the infection get started?

      • Rupture of an organ (ulcerative colitis, appendicitis)

      • Abscess (ulcerative colitis, pelvic inflammatory disease)

      • Mechanical perforation (knife wound, etc.)

      • Spontaneous peritonitis (long-standing ascites)

      • Peritoneal dialysis (contaminated equipment)


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    Peritonitis, cont.

    • Signs and symptoms:

      • Diffuse abdominal pain

      • Nausea, vomiting, dehydration

      • Reduced urine output

      • Intestinal paralysis

    • Treatment:

      • Antibiotics, surgery if necessary

    • Massage?

      • This is a medical emergency; massage is systemically contraindicated until all signs of infection have passed


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