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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
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
chapter 7 digestive system conditions introduction2
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
celiac disease
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
celiac disease cont
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
celiac disease cont5
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
celiac disease cont6
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!
celiac disease cont7
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
crohn disease
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
crohn disease cont
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
crohn disease cont10
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…
crohn disease cont11
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
crohn disease cont12
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
esophageal cancer
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%
esophageal cancer cont
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
esophageal cancer cont15
Esophageal Cancer, cont.
  • Metastasis:
    • Directly to nearby structures:
      • Trachea, diaphragm, aorta, vena cava
    • Through lymphatics:
      • Lungs, liver, bones
    • Through blood:
      • Uncommon
esophageal cancer cont16
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
esophageal cancer cont17
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
esophageal cancer cont18
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
gastroenteritis
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
gastroenteritis cont
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.
gastroenteritis cont21
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
gastroenteritis cont22
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
gastroenteritis cont23
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
gastroesophageal reflux disease gerd
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
gastroesophageal reflux disease gerd cont
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
gastroesophageal reflux disease gerd cont26
Gastroesophageal Reflux Disease (GERD), cont.
  • Complications:
    • Respiratory injury (gastric contents are inhaled)
    • Ulcers in esophagus
    • Stricture
    • Barrett’s esophagus, risk of esophageal cancer
gastroesophageal reflux disease gerd cont27
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
gastroesophageal reflux disease gerd cont28
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
gastroesophageal reflux disease gerd cont29
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
stomach cancer
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
stomach cancer cont
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
stomach cancer cont32
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
stomach cancer cont33
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%
stomach cancer cont34
Stomach Cancer, cont.
  • Massage?
    • Same guidelines as other clients with cancer:
      • Work with health care team to maximize benefits, minimize risks
ulcers
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
ulcers cont
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
ulcers cont37
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
ulcers cont38
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
appendicitis
Appendicitis
  • Inflammation, usually with infection, of vermiform appendix (suspended from cecum)
  • Incidence:
    • 1:1,000/year
    • Approximately 7% will eventually have appendicitis
appendicitis cont
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
appendicitis cont41
Appendicitis, cont.
  • Complications:
    • Peritonitis
  • Diagnosis:
    • Still difficult; resembles gallstones, pancreatitis, Crohn disease, ulcerative colitis, diverticulitis, pelvic inflammatory disease, ectopic pregnancy…
appendicitis cont42
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
colorectal cancer
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
colorectal cancer cont
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
colorectal cancer cont45
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?
colorectal cancer cont46
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)
colorectal cancer cont47
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
colorectal cancer cont48
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
diverticular disease
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
diverticular disease cont
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
diverticular disease cont51
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
diverticular disease cont52
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
irritable bowel syndrome ibs
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
irritable bowel syndrome ibs cont
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
irritable bowel syndrome ibs cont55
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
irritable bowel syndrome ibs cont56
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
ulcerative colitis
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
ulcerative colitis cont
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)
ulcerative colitis cont59
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
ulcerative colitis cont60
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
ulcerative colitis cont61
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
cirrhosis
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
cirrhosis cont
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”
cirrhosis cont64
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
cirrhosis cont65
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
cirrhosis cont66
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
gallstones
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
gallstones cont
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
gallstones cont69
Gallstones, cont.
  • Contributing factors:
    • Obesity
    • Estrogen
    • Race, gender, age
    • Cholesterol-lowering drugs
    • Diabetes
    • Rapid weight loss
    • Fasting
gallstones cont70
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
gallstones cont71
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
hepatitis
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
hepatitis cont
Hepatitis, cont.
  • Signs and symptoms:
    • Severity and duration of symptoms depends on type of infection
      • Malaise
      • Nausea
      • Fatigue
      • Jaundice
hepatitis a
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
hepatitis a cont
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
hepatitis b
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
hepatitis b cont
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
hepatitis c
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
hepatitis c cont
Hepatitis C, cont.
  • Communicability:
    • Shared fluids
  • Treatment:
    • Antivirals (the sooner the better)
    • No vaccine is available
hepatitis general
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
jaundice
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
jaundice cont
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
jaundice cont83
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)
jaundice cont84
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
liver cancer
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
liver cancer cont
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
liver cancer cont87
Liver Cancer, cont.
  • Risk factors:
    • HBV, HCV infection
    • Alcoholism
    • Hemochromatosis
    • Cirrhosis
    • Aflatoxin B1 (toxin common in Asia, Sub-Saharan Africa)
liver cancer cont88
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
liver cancer cont89
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%
liver cancer cont90
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
pancreatic cancer
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
pancreatic cancer cont
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
pancreatic cancer cont93
Pancreatic Cancer, cont.
  • Risk factors:
    • Age, gender, race
    • Smoking
    • Chronic pancreatitis
    • Diabetes
    • Diet
    • Colon cancer, breast cancer genes
    • History of melanoma
pancreatic cancer cont94
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
pancreatic cancer cont95
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
pancreatic cancer cont96
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
pancreatitis
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
pancreatitis cont
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
pancreatitis cont99
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
pancreatitis cont100
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
candidiasis
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
candidiasis cont
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…
candidiasis cont103
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)
candidiasis cont104
Candidiasis, cont.
  • Massage?
    • For severe problems, get information on underlying problems (immune weakness, etc.)
    • For chronic problems, massage may be safe and appropriate
peritonitis
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)
peritonitis cont
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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