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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

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    1. 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

    2. 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

    3. 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

    4. 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

    5. 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

    6. 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!

    7. 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

    8. 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

    9. 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

    10. 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…

    11. 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

    12. 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

    13. 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%

    14. 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

    15. Esophageal Cancer, cont. • Metastasis: • Directly to nearby structures: • Trachea, diaphragm, aorta, vena cava • Through lymphatics: • Lungs, liver, bones • Through blood: • Uncommon

    16. 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

    17. 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

    18. 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

    19. 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

    20. 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.

    21. 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

    22. 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

    23. 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

    24. 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

    25. 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

    26. Gastroesophageal Reflux Disease (GERD), cont. • Complications: • Respiratory injury (gastric contents are inhaled) • Ulcers in esophagus • Stricture • Barrett’s esophagus, risk of esophageal cancer

    27. 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

    28. 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

    29. 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

    30. 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

    31. 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

    32. 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

    33. 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%

    34. Stomach Cancer, cont. • Massage? • Same guidelines as other clients with cancer: • Work with health care team to maximize benefits, minimize risks

    35. 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

    36. 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

    37. 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

    38. 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

    39. Appendicitis • Inflammation, usually with infection, of vermiform appendix (suspended from cecum) • Incidence: • 1:1,000/year • Approximately 7% will eventually have appendicitis

    40. 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

    41. Appendicitis, cont. • Complications: • Peritonitis • Diagnosis: • Still difficult; resembles gallstones, pancreatitis, Crohn disease, ulcerative colitis, diverticulitis, pelvic inflammatory disease, ectopic pregnancy…

    42. 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

    43. 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

    44. 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

    45. 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?

    46. 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)

    47. 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

    48. 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

    49. 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

    50. 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