SysPath: GI Tract 1

Diseases of the Gastrointestinal System Part 1

• Disorders covered include disorders of the esophagus, stomach, inflammatory bowel disease (Crohn's/UC), celiac disease, and malabsorption syndrome.

Disorders of the Esophagus

• Includes hiatal hernia and GERD.

Hiatal Hernia

• Definition: A portion of the stomach protrudes through the esophageal hiatus.
• Prevalence: Affects approximately 15% of the population, potentially rising to 60% in those over 60.
• Symptoms: Typically, few people experience symptoms. Presentation can range from minor reflux to severe reflux, indigestion, bloating, and dysphagia.
• Etiology: Unknown for most cases, but risk factors include age-related diaphragm changes (over 50), trauma, or surgery. Other factors include constant pressure on surrounding muscles from coughing, vomiting, lifting, or exercising. Obesity also increases risk.
• Types:
  • Sliding hernia (Type I): 95% of cases, where the upper part of the stomach slides up through the diaphragm.
  • Paraesophageal hernia (Type II): 5% of cases, where the stomach is beside the esophagus rather than above it.
• Diagnosis: Barium x-ray.
• Treatment: Most sliding hernias do not need treatment.
  • Lifestyle changes (head of bed elevation, avoiding large meals before bed, weight loss, stress reduction, quitting smoking)
  • Medications (H2 blockers or PPI's)
  • Surgery for paraesophageal hernias causing symptoms.
• Signs and symptoms:
  • Most sliding hernias are asymptomatic.
  • Symptoms are most noticeable after eating and/or while lying down,
  • Commonly include indigestion, dull chest pain, shortness of breath (SOB), heart palpitations.
  • Increased frequency with trunk flexion, straining, heavy lifting, pregnancy.
  • Microscopic or massive bleeding is rare.
• Complications: Strangulation (painful and emergent complication), where the stomach is pinched by the diaphragm, and blood supply is cut off. Symptoms include chest pain, bloating, belching, and dysphagia.

Gastroesophageal Reflux Disease (GERD)

• Definition: Acid and enzymes from the stomach reflux into the esophagus, causing inflammation (reflux esophagitis).
• Etiology: Malfunction of the lower esophageal sphincter (LES) allows stomach contents to enter the esophagus. Risk factors include hiatal hernia, obesity, pregnancy, fatty, chocolate, caffeinated, carbonated drinks, alcohol, and smoking.
• Signs and Symptoms: Heartburn, regurgitation. Pain may extend to neck, throat, face. Other possible symptoms include sore throat, hoarseness, excessive salivation, and sensation of a lump in the throat, as well as a dry cough. Bleeding can be mild or severe.
• Complications: Esophageal ulcers due to chronic reflux (presenting similarly to heartburn), strictures, dysphagia, SOB, wheezing, Barrett's esophagus (metaplastic changes).
• Diagnosis: Based on symptoms; special tests may be used if diagnosis is unsure or if treatment is ineffective.
  • Endoscopy, x-rays, LES pressure measurement, and esophageal pH testing.
• Treatment: Lifestyle changes (similar to hiatal hernia),
  • Dietary changes (reducing irritating foods),
  • Parasympathetic stimulators to tighten LES.
  • H2 blockers or PPI's to reduce acid.
• Massage implications: No contraindications, but positioning and timing of massage should be considered to ensure patient comfort.

Disorders of the Stomach

• Diaphragmatic hernia, Pyloric stenosis, Gastritis, Peptic Ulceration, Gastric cancer

Diaphragmatic Hernia

• Definition: Protrusion of organs through a weakened diaphragm. Specifically, organs other than through the esophageal hiatus.
• Etiology:
  • Congenital: An embryological defect of the diaphragm.
  • Acquired: Typically blunt force trauma to the chest/abdomen.
• Signs and symptoms: Abdominal pain, decreased breath sounds, SOB, bowell sounds in the chest, possible visible bulge. Most adults are asymptomatic.
• Complications: Incarceration of organs, strangulation resulting in perforation/peritonitis, surgical emergency.
• Diagnosis: A medical professional will examine to determine cause.
• Treatment: Immediate surgical repair is required for congenital cases within 24-48 hours of diagnosis; surgical repair is indicated as soon as possible for acquired cases once diagnosed.
• Massage Implications: Local contraindication for performing massage over the area.

Pyloric Stenosis

• Definition: Congenital or acquired narrowing of the pylorus (the opening between the stomach and duodenum).
• Etiology: Congenital (more common) and idiopathic; possible genetic component; it normally becomes apparent during the first month of life. It may be linked to other genetic conditions such as Turner Syndrome, Trisomy 18 and esophageal atresia.
  Acquired: hypertrophy from gastritis and/or peptic ulcers near the gastric antrum.
• Signs and Symptoms:
  • Regurgitation
  • Persistent and projectile non-bilious vomiting after feeding, often leading to dehydration and failure to thrive (FTT).
  • Infants may seem hungry and want to feed again after vomiting.
  • Visible peristalsis and a palpable olive-sized mass in the abdomen.
• Diagnosis: Abdominal ultrasound.
• Treatment: Surgical muscle splitting (pyloromyotomy). IV fluids for dehydration.
• Massage Implications: Local Contraindication.

Acute Gastritis

• Definition: A transient inflammation of the gastric mucosa with acute inflammatory cells. Characterized by hemorrhagic defects extending through the mucosa.
• Etiology: Non steroidal anti-inflammatory drugs (NSAIDS), Helicobacter pylori (H. pylori) infections, alcohol, smoking and Crohn's Disease. Emotional distress, physical stress, severe burns or major injuries.
• Signs and Symptoms: Variable or none. Typically include epigastric pain/pressure, indigestion, and nausea or vomiting. More severe symptoms include overt hemorrhage, massive hematemesis, melena, anemia, fatigue/weakness, light-headedness.
• Complications: Gastric perforation/peritonitis, significant bleeding, chronic gastritis/gastric atrophy.
• Diagnosis: The doctor should determine the suspected cause. Symptoms, history and/or diagnostic tests.
• Treatment: Medication- reduce cause of gastritis, for example, stopping NSAID use; eradication of H. pylori; supportive care for the symptoms (such as providing IV fluids).

Chronic Gastritis

• Definition: Inflammation of the gastric mucosa with infiltration of lymphocytes and plasma cells. Characterized by mucosal atrophy (thinning of the mucous membrane) and possible intestinal metaplasia.
• Etiology: Autoimmune or environmental factors such as H. pylori infection. Other factors include non steroidal anti-inflammatory drugs (NSAIDs), alcohol, smoking, and Crohn's Disease.
• Signs and Symptoms: Variable or none. If symptoms occur they include mild/vague dyspepsia, poor digestion, and a decrease in protein breakdown. If symptoms occur in this case, they include pernicious anemia, polyneuropaties (due to lack of B12), malabsorption.
• Treatment: Stopping irritating drugs (especially NSAIDS); Eradication of H. pylori; dietary changes, especially with regards to foods that cause indigestion.

Peptic Ulcer Disease (PUD)

• Definition: Sharply demarcated, round or oval ulcerations in the lining of the stomach or duodenum; can be acute or chronic.
• Anatomical Classifications:
  • Duodenal (most common): Ulcers in the first few inches of the duodenum.
  • Gastric: Occur along the lesser curvature and the antrum of the stomach.
  • Marginal: Occur at the juncture of the stomach and intestine where the stomach has been surgically removed in the past.
• Etiology: Imbalance of gastrointestinal mucosal defense mechanisms against damaging forces such as HCI and pepsin. Main cause is H. pylori; also NSAIDs, corticosteroids, severe stress, smoking.
• Signs and Symptoms: ASx (about 70% of cases). Can also include epigastric pain (gnawing, burning, aching) that waxes and wanes; other possible sx: hematemesis, bloating, belching.
• Complications: Perforation; Bleeding (leading to iron-deficiency anemia); excessive scarring/cicatrization; gastric outlet obstruction.
• Diagnosis: Suspicion of PUD based on history and symptoms. Medical professional will recommend, and determine necessity and confirmation for diagnostic tests if necessary including endoscopy or barium x-ray, depending on the patient and situation. Also include checking for any signs of possible gastric cancer. If patient is 45+, check for gastric cancer symptoms.
• Treatment: Discontinue NSAID use; antibiotics for H. pylori; neutralizing/reducing stomach acid medications; usually take treatment for 4-8 weeks.

Gastric Cancer

• Definition: Primary adenocarcinomas, cancer from glandular cells in the stomach. About 95% of gastric cancers are this kind.
• Epidemiology: Most common in those over 50; highest incidence in Eastern Asia and lowest in Africa; more common in males. Over 4,000 diagnoses per year in Canada; a common cancer but 3rd highest mortality rate worldwide.
• Etiology: Risk factors include H. pylori infection, large/multiple gastric polyps, dietary links (smoked, salted, pickled foods, nitrates), smoking, and obesity.
• Signs and Symptoms: Often vague, such as early symptoms like burning pain/early satiety that are similar to peptic ulcer symptoms. More specific symptoms include weight loss, epigastric pain, nausea, dysphagia, and melena.
• Prognosis: Five-year survival rate is roughly 10%; diagnosis of the issue at a further stage, the chance of survival is reduced significantly; prognosis is better if the cancer has not spread deeply. Early metastasis to lymph nodes is poor prognostic indicator.
• Diagnosis: Medical professional will order diagnostic tests when they suspect gastric cancer through physical examination and patient history.
• Treatment: Surgical excision of the tumor portion; local lymph node removal, possible chemo and radiation; palliative options dependent on staging of the disease.

Disorders of the Intestines

• Celiac disease, Inflammatory bowel disease (IBD, Crohn's and UC), Malabsorption Syndrome

Celiac Disease

• Definition: Immune disorder triggered by gluten, a protein in wheat, barley, and oats. It's a cause of malabsorption syndrome. Genetic component in some, more prominent in family members.
• Pathophysiology: An immune response to gluten causes flattening of villi in the small intestine, leading to malabsorption.
• Etiology: Genetic component with increased risk in those with first/second degree relatives diagnosed with celiac disease. Common to also have other autoimmune diseases like Type 1 DM and autoimmune thyroiditis. Down's syndrome and Turner syndrome are also associated with an increased risk.
• Signs and Symptoms: Various symptoms depending on severity and damage. Common GI symptoms include chronic diarrhea (foul smelling stools), bloating, malnutrition, weight loss, malabsorption disorders such as iron deficiency anemia, calcium & vitamin D deficiency (osteopenia, tooth decay), vitamin B12 deficiency (pernicious anemia), generalized swelling. Extrinsic symptoms include dermatitis herpetiformis (pruritic papules and blisters).
• Diagnosis: Raises suspicion with physical examination and patient history and includes blood and stool tests and later confirmed by tissue biopsy.
• Treatment: Gluten-free diet; Steroid Use (corticosteroids) as appropriate for exacerbating symptoms.
• Prognosis: Potential for intestinal lymphoma and GI cancer; unknown if following a gluten-free diet can decrease the risk. Increased mortality compared to general population.
• Massage implications: No contraindications, however, depending on symptoms, adjustments to massage around the abdomen may be required if necessary.

Inflammatory Bowel Disease (IBD)

• Category: Two distinct diseases: Crohn's disease and ulcerative colitis.
• Inflammatory Conditions: Inflammation of the bowel.

Crohn's Disease

• Definition: An idiopathic, autoimmune inflammatory disease affecting any part of the GI tract, characterized by transmural inflammation and skip lesions.
• Etiology: Idiopathic and autoimmune.
• Pathophysiology: Affects the full thickness of the bowel (transmural inflammation). Commonly occurs in distal ileum and/or proximal colon. Skip lesions are also common.
• Signs and Symptoms: Abdominal pain, diarrhea (possibly bloody), fatigue, weight loss. Possible extraintestinal symptoms include enteropathic arthritis, sacroiliitis/ankylosing spondylitis, uveitis, erythema nodosum, pyoderma gangrenosum, stomatitis.
• Complications: Flare-ups (mild to severe), possible abdominal obstruction (scarring), abscess formation, fistulas, a possible increase in risk of colon cancer (depending on the extent and duration of the disease).
• Diagnosis: Based on patient history, physical examination, stool tests for inflammatory markers, blood test, imaging with x-rays or colonoscopy for confirmation. Possible tissue biopsy to confirm.
• Treatment: Aims to relieve symptoms and reduce inflammation. Includes treatment with anti-inflammatory medication, antidiarrheal medication, corticosteroids, and/or dietary changes. Possible surgical removal of segments of the digestive tract, surgical repair of fistulas to treat complications.
• Massage implications: Local contraindications during flare-ups.

Ulcerative Colitis

• Definition: A chronic, autoimmune inflammatory disease limited to the colon's mucosa; occurs in the rectum and sigmoid colon. Characterized by progressive lesions (not skip lesions).
• Etiology: Idiopathic and autoimmune; genetic connections, dietary and infection can worsen or cause the illness.
• Pathophysiology: Affects only the mucosal layer of the colon; occurs in a progressive pattern.
• Signs and Symptoms: Bloody diarrhea, frequent bowel movements, bowel urgency, lower abdominal pain and cramping; possible extraintestinal symptoms include enteropathic arthritis, ankylosing spondylitis, uveitis, erythema nodosum, pyoderma gangrenosum, and stomatitis
• Diagnosis: Patient's history, physical examination, stool tests for inflammatory markers, imaging to confirm suspected location and extent of the disease, possible tissue biopsy.
• Complications: Severe bleeding, possible colon distention (toxic megacolon), higher risk of colon cancer, perforation, and/or urgent colectomy.
• Treatment: Aims to reduce inflammation, control symptoms. Possible treatment with anti-inflammatory drugs, antidiarrheal drugs, corticosteroids, iron supplements, and possible dietary changes; possible surgery, and use of medication to manage symptoms or to reduce inflammation (including corticosteroids).
• Massage Implications: Local contraindications during flare-ups.

Malabsorption Syndrome

• Definition: Condition where the small/large intestine's ability to absorb nutrients is compromised.
• Etiology: Causes vary but are usually due to damage to the mucous membrane of the GI tract.
• Signs and Symptoms: Vary depending on nutrients which are malabsorbed. Symptoms may include weight loss; oily, light-colored, foul smelling stools; explosive diarrhea or bloating, flatulence; swelling, pale and/or dry skin, hair loss, bone pain; iron deficiency/microcytic anemia and related weakness or fatigue, or other vitamin deficiencies depending on the cause. Possible neurological or cardiovascular complications.
• Diagnosis: Suspicion is raised by patient's history and physical examination; stool tests for fat content may be needed. Blood tests are needed to rule out possible vitamin or nutrient deficiencies. Further investigation potentially includes imaging.
• Treatment: Depends on the cause (underlying disease, infections, medications) for effective treatment.