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A Massage Therapist’s Guide to Pathology, 5e. Chapter 8 Digestive System Conditions. Introduction. The Digestive Tract: Structure and Function Follow a piece of food through the GI tract: Mouth, esophagus, stomach, small intestine, large intestine, rectum, anus

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a massage therapist s guide to pathology 5e

A Massage Therapist’s Guide to Pathology, 5e

Chapter 8

Digestive System Conditions

  • The Digestive Tract: Structure and Function
    • Follow a piece of food through the GI tract:
    • Mouth, esophagus, stomach, small intestine, large intestine, rectum, anus
      • Gallbladder and pancreas secretions into small intestine
introduction cont1
Introduction, cont.
  • The Accessory Organs: structure and function
    • Liver, gallbladder, pancreas
  • The Liver
    • Hepatocytes have great power of regeneration
    • High blood supply: hepatic artery and portal vein
    • Sugar storage, protein synthesis, detoxification, recycling products of dead RBCs into bile
introduction cont2
Introduction, cont.
  • The Gallbladder
    • Receives bile, stores and concentrates it
    • Releases bile into duodenum
      • Emulsifies fats
  • The Pancreas
    • Endocrine and exocrine
    • Digestive juices and bicarbonate to neutralize acidic chime
    • Capable of autodigestion if duct is blocked
introduction cont3
Introduction, cont.
  • Digestive system problems and massage
    • Autonomic imbalance can cause GI discomfort; this is relieved by massage
    • Hard to tell whether symptoms are related to stress or more serious disease
    • Temporary relief from massage may delay an important diagnosis
    • If pain in a new pattern is present for 3 or more weeks, a client should consult a primary care physician
    • Red lights: severe localized pain, blood in stool, anemia, bloating, fever
digestive system conditions
Disorders of the Upper Gastrointestinal Tract

Celiac Disease

Esophageal Cancer


Gastroesophageal Reflux

Peptic Ulcers

Stomach Cancer

Disorders of the Large Intestine

Colorectal cancer

Diverticular disease

Irritable bowel syndrome

Disorders of the Accessory Organs




Liver Cancer

Pancreatic Cancer


Other Digestive System Conditions


Digestive System Conditions
celiac disease
Celiac Disease
  • Definition:
    • Villi are flattened, destroyed as reaction to gluten
    • Also called celiac sprue, nontropical sprue, gluten-sensitive enteropathy
    • 1% of US population has it, although majority undiagnosed
celiac disease cont
Celiac Disease, cont.
  • Etiology:
    • Gluten is in wheat, rye, barley, spelt, some other grains
    • Normally broken down into amino acids, absorbed through villi into circulatory system
    • With celiac disease: breaks down to gliadin, which triggers a mild-severe inflammatory response
    • Villi degenerate, can’t absorb anything: malabsorption, malnutrition
    • Occurs frequently with other autoimmune disorders: type 1 diabetes, hypothyroidism, lupus, rheumatoid arthritis, Sjogren syndrome
    • Genetic link easy to trace but age of onset varies greatly
    • Can cause rash: dermatitis herpetiformis
celiac disease cont1
Celiac Disease, cont.
  • Signs and Symptoms:
    • Malabsorption
    • GI pain, vitamin deficiency
    • Gas, bloating, diarrhea
    • Weight loss, failure to thrive, anemia, irritability, depression, muscle cramps
celiac disease cont2
Celiac Disease, cont.
  • Treatment
    • Avoid all gluten: villi grow back
  • Medications
    • Short-term steroidal anti-inflammatories (if restricting gluten does not improve symptoms quickly enough)
    • Vitamin and mineral supplements as necessary
    • Topical medications for dermatitisherpetiformis
celiac disease cont3
Celiac Disease, cont.
  • Massage
    • Risks
      • Abdominal work within comfort level, of course
      • Encourage clients to pursue nagging digestive symptoms
      • Skin rash that may be present is a local contraindication
    • Benefits
      • Clients who manage celiac disease with diet have no contraindications
    • Options
      • Use nongluten topical oil or lotion
esophageal cancer
Esophageal Cancer
  • Definition:
    • Malignant cells in esophagus
    • Squamous cell carcinoma at proximal end
    • Adenocarcinoma at distal end
esophageal cancer cont
Esophageal Cancer, cont.
  • Etiology:
    • Malignant cells at proximal end = squamous
      • Related to smoking, alcohol use
    • Malignant cells at distal end = adenocarcinoma
      • Related to Barrett esophagus, GERD
    • Metastasis through direct contact with other organs, lymphatics, bloodstream
    • Smoking, alcohol, GERD, obesity increase risk
    • Other risks include exposure to radiation at neck, toxic substances, HPV, drinking hot beverages
    • Worldwide studies reveal a shortage in some vitamins and minerals common for these patients
esophageal cancer cont1
Esophageal Cancer, cont.
  • Signs and Symptoms:
    • Early: no signs
    • Later: dysphagia, pain with swallowing, hoarseness, weight loss, chronic cough, hiccups, tracheo-esophogeal fistulas may cause fever and lung infection
esophageal cancer cont2
Esophageal Cancer, cont.
  • Treatment
    • Surgery, radiation
  • Medications
    • Chemotherapy
    • Photodynamic therapy
esophageal cancer cont3
Esophageal Cancer, cont.
  • Massage
    • Risks
      • Client may have reduced ability to adapt to changing environments
    • Benefits
      • May improve sleep and appetite; may reduce depression and anxiety; may help with pain
    • Respect effects of cancer and cancer treatments (Chapter 12)
  • Definition:
    • Inflammation of the stomach or small intestine
    • Related to infection, can be hard to discern causes
gastroenteritis cont
Gastroenteritis, cont.
  • Etiology:
    • Some pathogens secrete toxins that damage intestinal mucosa
    • Some pathogens invade healthy cells
    • When digestion is impaired, pathogens can become more aggressive
    • When GI tract is damaged:
      • Absorption of water, nutrients disrupted
      • Water and electrolytes are lost through vomiting and diarrhea
gastroenteritis cont1
Gastroenteritis, cont.
  • Causes:
    • Viruses:
      • Norwalk virus, rotavirus, hepatitis, enterovirus
    • Bacteria:
      • Salmonella, Shigella, Campylobacter, E. Coli: food poisoning
      • Helicobacter pylori (peptic ulcers)
      • Dangerous bacterial infection: Clostridium difficile
    • Parasites:
      • Giardia, cryptosporidium, and E. histolytica
gastroenteritis cont2
Gastroenteritis, cont.
  • Others:
    • Candidiasis, toxins, food allergies, medications, other diseases that can cause inflammation of the GI tract
  • Infectious forms are highly communicable
    • Oral-fecal
    • Contaminated water, ice
    • Food prepared on contaminated surfaces
  • Dehydration
  • Some pathogens can trigger other problems:
  • Guillain-Barre syndrome, meningitis, blood poisoning, renal failure
gastroenteritis cont3
Gastroenteritis, cont.
  • Signs and Symptoms:
    • Abdominal pain, nausea, vomiting, and diarrhea
    • Bloating, cramps, gas, mucous or blood in stool
gastroenteritis cont4
Gastroenteritis, cont.
  • Treatment
    • Usually self-limiting
    • Prevent through rigorous hygiene
  • Medications
    • Antibiotics can make symptoms worse
    • Anti-diarrhea meds are discouraged
    • IV fluids if necessary
gastroenteritis cont5
Gastroenteritis, cont.
  • Massage
    • Risks
      • Client may be uncomfortable, contagious
    • Benefits
      • Helps with parasympathetic state
gastroesophageal reflux disease
Gastroesophageal Reflux Disease
  • Definition:
    • Damage to the squamous epithelial lining of the esophagus
    • Chronic exposure to gastric juices from stomach
    • Problems at lower esophageal sphincter (LES)
gastroesophageal reflux disease cont
Gastroesophageal Reflux Disease, cont.
  • Etiology:
    • Four problems:
      • LES is too relaxed
      • LES doesn’t allow esophagus to clear out
      • Hiatal hernia
      • Slow stomach emptying, back-pressure at LES
    • Risk factors include
      • Pregnancy, obesity, smoking, diet, connective tissue diseases
      • Radiation for chest tumors, infection of the esophagus, some medications
gastroesophageal reflux disease cont2
Gastroesophageal Reflux Disease, cont.
  • Leads to several consequences:
    • Respiratory injury
      • Contents may be aspirated into lungs
    • Decay of tooth enamel
      • Acidic juices present in mouth
    • Ulcers
      • In esophagus: can bleed or become infected
    • Stricture
      • Thickening in esophageal wall
    • Barrett esophagus
      • Cells in esophagus begin to resemble stomach cells: precancerous for esophageal cancer
gastroesophageal reflux disease cont3
Gastroesophageal Reflux Disease, cont.
  • Signs and symptoms:
    • Bitter taste, heartburn, gas, indigestion, bloating, pain in chest
    • Can look like angina, heart attack
    • Aggravated by lying down, bending over
    • Also:
      • Dysphagia, coughing, wheezing, hemoptysis
gastroesophageal reflux disease cont4
Gastroesophageal Reflux Disease, cont.
  • Treatment
    • Management:
      • Lose weight; smaller portions; don’t lie down after meal; avoid caffeine, alcohol, nicotine; raise head of bed; wear loose clothing; heating pad on abdomen
    • Repair:
      • Surgery to repair LES, hiatal hernia
  • Medication
    • Antacids
    • H2 blockers to reduce histamine and acid production
    • Proton pump inhibitors to reduce acid production
    • Coating agents to protect tissues from acid
    • Promotility agents to promote peristalsis and tighten the lower esophagal valve
gastroesophageal reflux disease cont5
Gastroesophageal Reflux Disease, cont.
  • Massage
    • Risks
      • Caution not to exacerbate symptoms
        • Schedule hours after last meal
        • Not lying flat?
        • Caution around superior abdomen
    • Benefits
      • Can enjoy same benefits as the rest of the population if managed correctly
peptic ulcers
Peptic Ulcers
  • Definition:
    • Damage to esophagus, stomach, and duodenum wall
    • Perpetually open sore, invitation for infection
peptic ulcers cont
Peptic Ulcers, cont.
  • Etiology: what happens?
    • Pepsin, a protein-digesting enzyme contributes to development in esophagus, stomach, duodenum
    • Traditionally associated with stress, spicy food
    • More current understanding shows they are a multifactoral condition
peptic ulcers cont1
Peptic Ulcers, cont.
  • Stress and Ulcers
    • Aggressive features (acid, pepsin)
    • Defensive features (blood supply, mucous lining, bicarbonate)
    • Frequent fluctuations in stress can allow aggressive features to outweigh defensive ones
  • Helicobacter pylori and Ulcers
    • H. pylori is a bacillus with spiral-shaped flagella
    • Can “drill” into stomach, duodenal wall, create localized infection
peptic ulcers cont3
Peptic Ulcers, cont.
  • NSAIDs and Ulcers
    • Aspirin, ibuprofen, naproxen sodium
    • Inhibiting the cyclo-oxygenase-1 pathway
    • Impede the production of prostaglandins
    • Slows production of protective mucous
peptic ulcers cont4
Peptic Ulcers, cont.
  • Signs and symptoms:
    • Gnawing burning pain in chest, abdomen
    • Relieved by antacids, eating
    • Nausea, vomiting, loss of appetite, and bleeding into the GI tract
peptic ulcers cont5
Peptic Ulcers, cont.
  • Treatment
    • Surgical correction
    • Suspend medications that damage stomach lining
  • Medications
    • Antibiotics (only for H. pylori)
    • Bismuth (to protect stomach lining)
    • H2 blockers (limit histamine release)
    • proton pump inhibitors (limit acidity in the stomach)
peptic ulcers cont6
Peptic Ulcers, cont.
  • Massage
    • Risks
      • Parasympathetic press response stimulates digestion
      • Adjust for position, duration
    • Benefits
      • General parasympathetic benefits can be helpful
stomach cancer
Stomach Cancer
  • Definition:
    • Development of malignant tumors in the stomach
    • Has become fairly rare in the United States
    • 2nd leading cause of cancer death worldwide
stomach cancer cont1
Stomach Cancer, cont.
  • Etiology:
    • Most are adenocarcinoma
      • Probably related to diets high in pickled, salted, preserved food
      • Also related to H. pylori :
        • Converts nitrates and nitrites into carcinogens
    • Anything that impedes normal production of gastric juices raises risk:
      • H. pylori, gastritis, stomach surgery, pernicious anemia
    • Physical obstruction of food
    • Metastasizes through portal system to liver, or through lymph system
    • Adenomas = 90-95% stomach cancer
    • Others: non-Hodgkin lymphoma, carcinoid tumors, stromal cell tumors
stomach cancer cont2
Stomach Cancer, cont.
  • Signs and symptoms:
    • Feeling of fullness with little food
    • Abdominal pain above navel
    • Unintentional weight loss
    • Heartburn
    • Nausea, vomiting
    • Ascites
    • Small amount of blood in stool
    • Possible anemia
stomach cancer cont3
Stomach Cancer, cont.
  • Treatment
    • Radiation (external)
    • Surgery
  • Medications
    • Chemotherapeutic agents to limit neoplastic cell growth
    • Biologic therapies, including monoclonal antibodies to target cancer cells
stomach cancer cont4
Stomach Cancer, cont.
  • Massage
    • Risks
      • Treated aggressively; as with other cancers: respect challenges of cancer and cancer treatment
    • Benefits
      • May ease pain, anxiety, depression, sleeplessness, etc.
    • See more in Chapter 12
colorectal cancer
Colorectal Cancer
  • Definition:
    • Development of tumors anywhere in the large intestine
    • 101,000 diagnoses/year in the US
    • 49,000 deaths/year
    • Number 3 cause of death by cancer in the United States
    • Declining due to better screening and earlier treatment
colorectal cancer cont
Colorectal Cancer, cont.
  • Etiology:
    • Begins with development of adenomas: “polyps” (Fig. 8.6)
    • If present for long time:
      • Oncogenes activated
      • Tumor-suppressor genes inactivated
      • Cells replicate, don’t die off
      • Invade deeper layers off the colon, or obstruct lumen
      • Can metastasize through the lymph system to other places in the body, notably the brain, liver, and lungs
colorectal cancer cont1
Colorectal Cancer, cont.
  • Cause of polyps is unknown; 50% of older Americans have them
  • Triggers for mutation:
    • High fat foods?
colorectal cancer cont2
Colorectal Cancer, cont.
  • Risk factors:
    • Obesity, sedentary lifestyle
    • Family history
      • Familial adenomatous polyposis
      • Hereditary nonpolyposis colorectal cancer syndrome
      • These account for a small percentage of diagnoses
    • Inflammatory bowel disease
    • Age
colorectal cancer cont4
Colorectal Cancer, cont.
  • Signs and Symptoms:
    • Silent early
    • Later: anemia (bleeding tumors), constipation, narrowed stools, lower abdominal painfeeling BMs are incomplete, unintentional weight loss
colorectal cancer cont5
Colorectal Cancer, cont.
  • Treatment
    • Depends on stage at diagnosis
    • Surgery
    • Radiation
  • Medications
    • Chemotherapy
    • Biologic therapies specifically monoclonal antibodies that target cancer cells
colorectal cancer cont6
Colorectal Cancer, cont.
  • Massage
    • Risks
      • Adapt for treatment
    • Benefits
      • Can be helpful within limits set by cancer and cancer treatments
      • See Chapter 12
    • Options
      • Colostomy bag may be in use; ask the client how they are most comfortable
diverticular disease
Diverticular Disease
  • Definition:
    • Bulge in colon forming diverticulum
    • Diverticulosis: presence of bulges
    • Diverticulitis: infection of bulges
    • One-half of 60-80 year olds have diverticulae
    • Most common with eating habits with white flour, animal fats
diverticular disease cont
Diverticular Disease, cont.
  • Etiology:
    • Multifactoral:
      • Inefficient motility
      • Poor strength in colon wall
      • Lack of sufficient dietary fiber
    • Diverticulae form during strong colon contraction
      • Mucosa, submucosa herniated through muscularis
      • May be filled with fecal material and bacteria
    • Usually at sigmoid flexure or descending colon
    • Can be anywhere in GI tract
diverticular disease cont1
Diverticular Disease, cont.
  • Complications are rare but can include
    • Bleeding
    • Abscesses
    • Perforation and rupture
    • Blockage
    • Fistulas
diverticular disease cont3
Diverticular Disease, cont.
  • Signs and symptoms:
    • May be silent
    • With infection: bloating, fever, nausea, cramping, pain usually on lower left side of abdomen
    • May have sudden or gradual onset
diverticular disease cont4
Diverticular Disease, cont.
  • Treatment
    • Prevent with high fiber diet, adequate water
    • Surgical correction if necessary
  • Medications
    • Antibiotics when infection is present
    • Analgesics as necessary
    • Anti-inflammatories as necessary
    • Anti-spasmodics to decrease colon pressure
diverticular disease cont5
Diverticular Disease, cont.
  • Massage
    • Risks
      • Important to advise client to pursue formal diagnosis if showing upset digestive symptoms for more than two weeks
      • If diagnosed, deep abdominal work is contraindicated
      • Acute infection systemically contraindicates bodywork
    • Benefits
      • As long as care is taken not to exacerbate symptoms, bodywork can be a helpful strategy to deal with anxiety and abdominal pain
irritable bowel syndrome
Irritable Bowel Syndrome
  • Definition:
    • Digestive system dysfunction without structural changes
    • Also called spastic colon, irritable colon, mucus colitis, functional bowel syndrome
irritable bowel syndrome cont
Irritable Bowel Syndrome, cont.
  • Etiology:
    • Colon is hyperreactive: small stimuli create big responses
    • Peristalsis is irregular, uncoordinated
    • Hypersensitivity to pain, pressure in colon
    • Psychosocial factors
    • Dysfunction in brain-gut axis
      • Appears with chronic fatigue syndrome, fibromyalgia
    • Possible low-grade inflammation for long-term sufferers
irritable bowel syndrome cont2
Irritable Bowel Syndrome, cont.
  • Types of Irritable Bowel Syndrome
    • IBS-D: primary symptom is diarrhea
    • IBS-C: primary symptom is constipation
    • IBS-M: both, within a short time span
    • IBS-A: alternating symptoms
irritable bowel syndrome cont3
Irritable Bowel Syndrome, cont.
  • Signs and symptoms:
    • Abdominal pain, cramps, bloating, constipation/diarrhea, general malaise
    • Recurrent abdominal pain at least 3 days every month
    • Pain with defecation
    • Changes in stool frequency and appearance
    • No structural changes in colon
      • If fever or blood in stool, IBS is not the cause
irritable bowel syndrome cont4
Irritable Bowel Syndrome, cont.
  • Treatment
    • Depends on the individual
    • Manage diet, stress
    • Eliminate nicotine, alcohol, caffeine, sorbitol, maybe dairy
    • Supplement fiber
    • Alternative medicine: acupuncture, peppermint, probiotics
irritable bowel syndrome cont5
Irritable Bowel Syndrome, cont.
  • Medications
    • Antispasmodics
    • Fecal binders for diarrhea
    • Bulking agents
    • Laxatives for constipation
    • Antidiarrheals
    • Antacids
    • Antidepressants/antianxiety for stress management
    • Antibiotics if low-grade bacterial infection confirmed
irritable bowel syndrome cont6
Irritable Bowel Syndrome, cont.
  • Massage
    • Risks
      • Clients can be extremely self-conscious about passing gas, nervous about touch in general
      • Make it difficult for a person to enjoy the experience of massage
    • Benefits
      • Can be useful for stress management if well tolerated
  • Definition:
    • Greek “kirrhos” = “yellow condition”
    • Replacement of healthy hepatocytes with non-functioning scar tissue
    • Can interfere with every liver function
cirrhosis cont
Cirrhosis, cont.
  • Etiology:
    • Hepatocytes usually replace themselves easily, but they can lose that ability:
    • Chronic inflammation, irritation:
      • Suppresses regeneration
      • Stimulates production of collagen, scar tissue
    • Channels blocked, chemical production reduced, function lost
    • Hobnail liver functioning cells interspersed with scar tissue
cirrhosis cont2
Cirrhosis, cont.
  • Etiology, cont.
    • Causes include:
      • Alcoholism, hepatitis C, B, D, drug related, autoimmune hepatitis
      • NAFLD: non-alcoholic fatty liver disease
        • Deposition of fatty tissue in liver: obesity, type 2 diabetes, high triglycerides
      • NASH: non-alcoholic steatohepatitis
        • Inflammation of fatty tissue in liver
      • Other causes: obstruction of bile duct, toxins, heart failure, some congenital diseases
cirrhosis cont4
Cirrhosis, cont.
  • Complications:
    • Portal hypertension: liver is congested, can’t accept blood from major vessels
    • Can lead to
      • Splenomegaly (enlarged spleen)
        • Risk of rupture and internal hemorrhage
      • Ascites
        • Fluid in peritoneal cavity
        • Can get infected
        • Can seep across the diaphragm to cause pleural effusion
      • Internal varices
        • Can hemorrhage during vomiting
cirrhosis cont6
Cirrhosis, cont.
  • Complications, cont.
    • Bleeding, bruising
      • From inadequate clotting factors
    • Osteoporosis
      • From inadequate Vitamin D
    • Muscle wasting
      • From short supply of enzymes that aid in protein metabolism
    • Jaundice
      • Bilirubin does not get recylced
cirrhosis cont8
Cirrhosis, cont.
  • Complications, cont.
    • Systemic edema
      • Significant reduction of albumin, cannot maintain proper body fluids
    • Hormone disruption
      • Feminizes men, masculanizes women, decreased sex drive for both
    • Encephalopathy
    • Kidney failure, hepatorenal syndrome
    • Liver failure
    • Liver cancer
cirrhosis cont9
Cirrhosis, cont.
  • Signs and symptoms:
    • Silent or subtle early:
    • Nausea, vomiting, weight loss, rashes
    • Later: complications listed above
cirrhosis cont10
Cirrhosis, cont.
  • Treatment
    • Stop liver damage (quit drinking)
    • Surgical repair for internal varicosities
    • Dialysis
    • Liver transplant
    • Living donor is possible
cirrhosis cont11
Cirrhosis, cont.
  • Medications
    • Diuretics
    • Beta blockers
    • Hepatitis may be treated with interferon
    • Antacids
    • Levulose to help eradicate ammonia
    • Steroidal anti-inflammatories for autoimmune problems
cirrhosis cont12
Cirrhosis, cont.
  • Massage
    • Risks
      • Advanced disease contraindicates circulatory massage (fluid movement) as clients do not have the capacity to adapt
    • Benefits
      • Gentle, reflexive (non-circulatory) bodywork can be safe and helpful for anxiety reduction
      • If client is encouraged to exercise to promote muscle recovery, massage will fit well into this context
  • Definition:
    • Concentrated deposits of bile salts or pigments in the gallbladder
    • Gallbladder = cholecyst
    • Stones here = cholelithiasis
    • Inflammation here = cholecystitis
    • Stone lodged in common bile duct = choledocholithiasis
    • Inflammation of ducts = cholangitis
    • 800,000 hospitalizations, 500,000 surgeries/year
    • Women > men 2:1
gallstones cont
Gallstones, cont.
  • Etiology:
    • Bile from liver drips into gallbladder through cystic duct
    • Gallbladder squeezes bile into duodenum through common bile duct
    • Pancreas shares a section of common bile duct
    • Bile emulsifies fats, made of water, bile salts, bilirubin, cholesterol
    • Cholesterol and/or bilirubin can crystallize in gallbladder
    • Most gallstones = cholesterol
    • Others= bilirubin (indicates underlying disorders)
gallstones cont2
Gallstones, cont.
  • Etiology cont.
    • Factors increasing risk of developing cholesterol stones
      • Obesity
      • Increased estrogen levels
      • Race (Native American, Mexican)
      • Gender
      • Cholesterol-lowering drugs (concentrate)
      • Diabetes (high triglycerides)
      • Rapid weight loss (liver metabolizes fats for fuel, stones common complication of bariatric surgery)
      • Fasting (reduces gall bladder emptying)
      • History of gallstones
      • Other diseases
gallstones cont3
Gallstones, cont.
  • Signs and symptoms:
    • Symptoms develop when a stone lodges in a duct: biliary colic
    • Extreme local pain rises to peak, then subsides as stone moves
    • Refers pain to mid-back, scapula, right shoulder
gallstones cont4
Gallstones, cont.
  • Treatment
    • Surgery to remove gallbladder; usually laparascopic
    • Endoscopic retrograde cholangiopancreatography (ERCP): scope that may dislodge stones while sparing gallbladder
    • Digestive supplements to aid fat digestion
  • Medications
    • Analgesics for acute gallbladder attacks
    • Ursodeoxycholic acid or chenodeoxycholic acid for 6 to 18 months to dissolve small cholesterol based stones
gallstones cont5
Gallstones, cont.
  • Massage
    • Risks
      • Contraindicated during attack
      • Costal angle on right side a local caution if client knows stones are present
    • Benefits
      • History of stones or surgery is fine for massage
  • Definition:
    • Inflamed liver
    • Usually a viral infection (hepatitis A-G)
    • Almost always A B or C
hepatitis cont
Hepatitis, cont.
  • Etiology:
    • Viral attacks on hepatocytes
    • Exposure to one type confers no protection from others
hepatitis cont1
Hepatitis, cont.
  • Four basic phases:
    • Phase 1:
      • New infection and viral replication: no symptoms
    • Phase 2:
      • Prodromal stage: symptoms include food aversion, nausea, vomiting, malaise
    • Phase 3:
      • Icteric stage: yellowing skin (icterus), pale stools, dark urine, and hepatomegaly
    • Phase 4:
      • Convalescence: liver heals, jaundice resolves, enzymes return to normal levels, health is restored
hepatitis cont2
Hepatitis, cont.
  • Types of Hepatitis
    • Hepatitis A
      • Also called infectious hepatitis
      • Short-term, acute, lifelong immunity
      • Incubation is 2-6 weeks (contagious during this time)
      • May not fully recover for several months
      • 30% adults have antibodies showing exposure
    • Communicability of hepatitis A:
      • Oral-fecal contamination
      • Can also be blood-borne
hepatitis cont3
Hepatitis, cont.
  • Hepatitis B
    • Exposure to intimate fluids (blood, semen, breast milk, vaginal secretions)
    • Long-term, subtle symptoms, chronic inflammation causes damage
    • Incubates 2-6 months (communicable)
    • About 5% develop chronic infections: long-term carriers
    • Stable outside the host, can be active for one week
hepatitis cont4
Hepatitis, cont.
  • Hepatitis C
    • Used to be called “hepatitis non-A non-B”
    • Long-term, chronic infections
    • Damages liver slowly, symptoms may not develop until decades after exposure
hepatitis cont5
Hepatitis, cont.
  • Other types of hepatitis:
    • Hepatitis D is incomplete: only works with hepatitis B
    • E, F, G rare in the United States
    • Can be complication of mononucleosis, reaction to meds, autoimmune disease
    • Nonviral hepatitis is an occasional reaction to certain medications or autoimmune attack
hepatitis cont6
Hepatitis, cont.
  • Signs and Symptoms
    • General malaise, weakness, fever, nausea, food aversion, sometimes jaundice
    • HAV most extreme symptoms for shortest time
    • HBV and HBC more subtle until much liver function is lost
hepatitis cont7
Hepatitis, cont.
  • Treatment
    • HBV, HBC treated with rest, good nutrition, and patients during a long recovery period
    • Liver transplant in serious cases
  • Medications
    • HAV typically treated with a shot of immunoglobin
    • HBV, HBC treated with antiviral agents
hepatitis cont8
Hepatitis, cont.
  • Massage
    • Risks
      • Any bodywork that puts adaptive stress on the body may be overwhelming during acute phase
      • Some types of hepatitis are contagious without direct contact with body fluids which presents a risk to the therapist
    • Benefits
      • Appropriate for non-acute if client can adapt
      • Can improve QOL for a person dealing with a challenging situation
      • A client who has fully recovered can enjoy all benefits
liver cancer
Liver Cancer
  • Definition:
    • Hepatocellular carcinoma (HCC): originates in liver
    • (As opposed to metastatic liver disease)
    • Worldwide liver cancer is common and deadly
    • Fairly rare in the United States: 18,000/year
    • Rates more than doubled between in the past 20 years (links between cirrhosis, NAFLD, HBV, HCV)
liver cancer cont
Liver Cancer, cont.
  • Etiology:
    • Hepatocytes replicate out of control
    • History of hepatitis B or C, alcoholism, cirrhosis contribute to replication
    • Tumors may be single or in disconnected areas
    • Highly invested with blood vessels – raises risk of metastasis (usually to lungs)
liver cancer cont1
Liver Cancer, cont.
  • Risk Factors:
    • Hepatitis B (HBV) infection: especially if infection occurs in childhood
    • Hepatitis C (HCV) infection: 5-10% hepatitis C patients eventually develop liver cancer
    • Alcoholism: cessation of alcohol use may trigger cellular mutation—healing process gone wrong
    • Hemachromatosis – genetic blood disorder, too many RBCs
    • NAFLD: can lead to cirrhosis
    • Cirrhosis: chronic, long term liver damage
    • Aflatoxon B1: from Aspergillus flavus, grows on peanuts and grains stored in hot, humid conditions, extremely potent carcinogen
liver cancer cont2
Liver Cancer, cont.
  • Signs and Symptoms:
    • Tumors interfere with normal liver function
    • Symptoms may be lost in cirrhosis, hepatitis
    • Vague abdominal pain, unintended weight loss, food aversion, muscle wasting, ascites, fever, abdominal mass, possible jaundice
    • Blood test for AFP (present in 60% of cases)
liver cancer cont3
Liver Cancer, cont.
  • Treatment:
    • Frequent recurrence
    • Tends to be aggressive, appear with other diseases that compromise health
    • Surgery, transplant (problematic with other health conditions)
    • Liver doesn’t tolerate chemotherapy, radiation
    • Other options:
    • Burn/freeze cells through laparscopic or percutaneous instruments; inject ethanol into tumor; block blood vessels that supply tumors
liver cancer cont4
Liver Cancer, cont.
  • Medications
    • Chemotherapy by catheter
    • Oral antiangiogenic agents
    • Injections of ethanol
    • Medications to manage pain, encephalopathy, ascites
liver cancer cont5
Liver Cancer, cont.
  • Massage
    • Risks
      • Same guidelines as other cancers: stay within limits, respect challenges of cancer and cancer treatments (see Chapter 12)
    • Benefits
      • May provide comfort, pain relief, and other benefits at end of life
pancreatic cancer
Pancreatic Cancer
  • Definition:
    • Uncontrolled growth of cells in pancreas
    • Usually exocrine ducts, can affect hormone-producing cells
    • Aggressive, metastasizes easily, Number 4 cause of death by cancer in the United States
    • 43,000 diagnoses/year
pancreatic cancer cont
Pancreatic Cancer, cont.
  • Etiology:
    • Several mutations of genes in cells that line exocrine ducts: adenocarcinomas
    • In islet cells: neuroendocrine tumors
    • Both types grow quickly, invade tissues through direct spreading:
      • Duodenum, stomach, peritoneal wall
      • Cells in blood or lymph usually go to liver
pancreatic cancer cont1
Pancreatic Cancer, cont.
  • Etiology cont.
    • Risk Factors
      • Age (most are 60-80 years old)
      • Race (African-Americans slightly more often
      • Smoking
      • History of type 2 diabetes
      • Chronic pancreatitis related to alcoholism
      • Obesity and diet
      • Inherited characteristics
pancreatic cancer cont2
Pancreatic Cancer, cont.
  • Types of Pancreatic Cancer
    • Adenocarcinoma
      • Exocrine ducts, affects secretions of ezymes, sometimes blocks pancreatic duct; most common
    • Neuroendocrine tumors
      • Cancer of endocrine cells of the pancreas, specifically the islets
pancreatic cancer cont3
Pancreatic Cancer, cont.
  • Signs and Symptoms:
    • Early signs are subtle: abdominal discomfort, mid-back pain, loss of appetite, unintended weight loss
    • If tumor obstructs the bile duct: jaundice
    • Later: difficulty with digestion, ascites, enlarged liver, spleen
    • If cancer affects islet cells: dysregulation of blood glucose
pancreatic cancer cont4
Pancreatic Cancer, cont.
  • Treatment
    • Resection if possible (usually not)
    • Chemo and radiation to slow progress, may be able to shrink tumor for surgery
    • Surgery very invasive and recurrence is very high
    • Hospice
  • Medications
    • Chemotherapy
    • Biologic or targeted therapy
    • Narcotic analgesics, sometimes with antidepressants
pancreatic cancer cont5
Pancreatic Cancer, cont.
  • Massage
    • Risks
      • Respect challenges of cancer and cancer treatments
      • See Chapter 12
    • Benefits
      • May be helpful for pain, anxiety, fear, QOL at end stages
  • Definition:
    • Inflammation of the pancreas
    • Triggered by alcohol binging, gallstones, toxic exposures, blunt trauma
    • Chronic pancreatitis related to long-term alcohol abuse
pancreatitis cont
Pancreatitis, cont.
  • Etiology:
    • If ducts are blocked or if cysts, abscesses develop pancreas will autodigest
pancreatitis cont1
Pancreatitis, cont.
  • Types of Pancreatitis
    • Acute pancreatitis
      • Sudden onset of symptoms show blockage of ducts
      • Alcohol use, blunt trauma, malformation, infection, gallstones, toxins, cystic fibrosis
      • Usually short-lived, can be severe
      • Cysts, abscesses, necrosis, circulatory shock, renal failure
pancreatitis cont3
Pancreatitis, cont.
  • Chronic pancreatitis
    • Long-term wear-and-tear leads to permanent damage
    • Usually related to alcohol abuse
    • May lead to pancreatic stones
    • Complications:
    • Pain, malabsorption, steatorrhea, bleeding, secondary diabetes
pancreatitis cont4
Pancreatitis, cont.
  • Signs and Symptoms:
    • Upper abdominal pain
    • Acute may have sudden onset nausea, fever, rapid pulse
    • Chronic: pain is episodic with increasing frequency; refers to back
    • Other: unintended weight loss, dysregulation of blood glucose, jaundice
pancreatitis cont5
Pancreatitis, cont.
  • Treatment
    • Depends on cause
    • No food by mouth to give time for organ healing
    • Remove gallstones, abscesses, dead tissue, repair ducts
    • Sever sensory neurons if necessary
  • Medications
    • Analgesics
    • Supplementary digestive enzymes if necessary
pancreatitis cont6
Pancreatitis, cont.
  • Massage
    • Risks
      • Unexplained abdominal/back pain: needs diagnosis
      • Avoid abdominal work; other supportive work with caution
    • Benefits
      • Those who have recovered can enjoy same benefits as general population
  • Definition:
    • Candida albicans = yeast-like fungi in digestive tract
    • Live in balance with intestinal bacteria
    • When balance is disturbed and they overgrow: candidiasis
candidiasis cont1
Candidiasis, cont.
  • Etiology:
    • Disruption in flora/fauna balance in GI tract
    • Candida becomes aggressive fungi, reproduce and spread
    • Especially a risk for immune-compromised
    • Can be triggered by antibiotic use, immune system dysfunction, undergoing treatment for cancer, thymus tumor, hormonal imbalances
candidiasis cont2
Candidiasis, cont.
  • Types of Candidiasis
    • Mucocutaneous
      • Appears on mouth or skin; can cause ulcers; can colonize fingernails and toenails
    • Vulvovaginitis
      • Appears around the vagina; can cause itching and burning and painful intercourse
    • Internal candidiasis
      • Invades GI tract, possibly other organs; rare in people who are essentially healthy
candidiasis cont3
Candidiasis, cont.
  • Signs and symptoms:
    • Mouth lesions: (thrush)
    • Vulvovaginitis
      • Other mild symptoms can include skin lesions, chemical sensitivities
      • Severe symptoms include fever, chills, organ failure
candidiasis cont4
Candidiasis, cont.
  • Treatment
    • Reestablish internal flora, dietary changes
  • Medications
    • Topical anti-fungals for skin outbreaks
    • Internal anti-fungals: can take a long time to be effective
candidiasis cont5
Candidiasis, cont.
  • Massage
    • Risks
      • Extreme cases linked to immune system dysfunction
    • Benefits
      • Can ejnoy same benefits as the rest of the population