GI Diseases: Hiatal Hernia

Diseases of the GI System: Part 1

• Includes disorders of the Esophagus and stomach, IBD, Celiac Disease, and Malabsorption Syndrome.

Hiatal Hernia

• A protrusion of a portion of the stomach through the esophageal hiatus.
• Affects about 15% of the population and may rise to 60% for those 60+.
• Most individuals do not experience symptoms, and treatment or surgery is rarely needed.
• Presents as minor to severe reflux.
• May cause indigestion, bloating, and/or dysphagia, or difficulty swallowing.
• Most hiatal hernias have an unknown cause, but risk increases with age, injury, congenital, or increased abdominal pressure.
• Classified based on the portion of the stomach that bulges through the diaphragm.

Sliding Hernia (Type I)

• The most common type of hiatal hernia at 95% of cases.
• Involves the protrusion of the LES and gastroesophageal junction through the diaphragm.
• Creates bell-shaped dilation due to construction of the LES constricted diaphragmatic narrowing.

Paraesophageal Hernia (Type II)

• Less common at 5% of hiatal hernia cases, but more severe.
• A fixed protrusion of a separate portion of the stomach into the thorax.
• LES and gastroesophageal junction remain below the diaphragm while the herniated portion is beside the esophagus.

Hiatal Hernia Signs and Symptoms

• Most sliding hernias are asymptomatic or present with minor symptoms, usually heartburn or indigestion.
• Common symptoms include indigestion, especially after lying down, dull chest pain, shortness of breath, and heart palpitations.
• Symptoms increase with trunk flexion, straining, heavy lifting, and pregnancy.
• Can lead to incarceration, especially in paraesophageal hernias.
• Microscopic or massive bleeding is rare in either type.
• Strangulation occurs when the stomach pinched by the diaphragm loses blood supply, causing emergent, painful complications usually associated with paraesophageal hernias.
• Symptoms include chest pain, bloating, belching, and dysphagia.
• GI perforation is severe and can lead to bacteria spreading to the peritoneum, causing widespread infection.
• A barium x-ray is preformed for diagnosis.

Hiatal Hernia Treatment

• Most sliding hernias do not require treatment.
• Lifestyle changes include raising the head of the bed, eating small meals, avoiding eating before sleep, weight loss, smoking cessation, and wearing looser clothing.
• Avoiding cola, acidic juices, alcohol, coffee, and spicy/fatty foods is also important.
• H2 blockers or PPIs may be prescribed.
• Paraesophageal hernias that cause symptoms should be surgically repaired to prevent strangulation.
• Massage is a local contraindication, so avoid or use light pressure over the affected area while remaining conscious of patient positioning and comfort during treatment.

Gastroesophageal Reflux Disease (GERD)

• A chronic condition where stomach acid and enzymes flow back into the esophagus, causing inflammation (reflux esophagitis).
• Stomach lining protects against acid, while the esophagus lacks this protection.
• Acid leads to inflammation and erosion.
• Heartburn is a symptom of chronic, consistent heartburn, but GERD is a more consistent, chronic disease.

GERD Etiology

• Caused by malfunction of the LES, allowing stomach contents into the esophagus.
• Risk factors include hiatal hernia, obesity, pregnancy, fatty/spicy foods, chocolate, caffeinated/carbonated drinks, alcohol, smoking, and certain drugs.
• Anticholinergic drugs, calcium channel blockers, progesterone, and nitrates may interfere with LES (lower esophageal sphincter) function.

GERD Signs and Symptoms

• Heartburn and regurgitation is a common symptom.
• Pain can extend to the neck, throat, and face (referral pattern).
• Other symptoms include sore throat, hoarseness, excessive salivation, sensation of a lump in the throat, and a dry cough.
• Slight or massive bleeding may occur because of inflammation, including red vomit or black, tarry stool (melena).

GERD Complications

• Esophageal ulcers occur due to chronic reflux.
• Stricture may develop because of chronic ulceration, resulting in dysphagia, shortness of breath, and wheezing.
• Barrett's Esophagus involves metaplastic changes due to acid irritation and is precancerous; may occur even without symptoms.
• The condition results in a switch of cell type from stratified squamous to columnar epithelium.

GERD Diagnosis

• Based on symptoms, and treatment can often start without tests.
• Special testing (endoscope, esophageal pH testing, x-rays, LES pressure measurement) is available if the diagnosis is unclear or treatment fails.

GERD Treatment

• Lifestyle changes are similar to those for hernias, including eating habits and removing irritating foods.
• Parasympathetic stimulators can help tighten the LES.
• H2 blockers or PPIs can be used to reduce acid.
• Massage has no contraindications, but be mindful of patient positioning and timing of massage.

Diaphragmatic Hernia

• Protrusion of organs into the thoracic cavity through a weakening in the diaphragm, excluding the esophageal hiatus.
• Stomach and/or intestines push through weakened opening.
• Etiology can be congenital, due to an embryologic defect of the diaphragm, or acquired, most commonly from blunt force trauma.

Diaphragmatic Hernia Signs and Symptoms

• Abdominal pain.
• Decreased breath sounds.
• Shortness of breath.
• Auscultation of bowel sounds in the chest.
• Potential bulge.
• Nearly half of adults have no symptoms.

Diaphragmatic Hernia Complications and Treatment

• Complications include incarceration of organs, strangulation, perforation, and peritonitis, creating a surgical emergency.
• Congenital hernias require surgical repair within 24–48 hours.
• Acquired hernias require surgical repair as soon as the patient presents with symptoms.
• Prognosis typically involves recurrence, if rare, but routine check-ups with CXR and PFTs are still recommended.
• Massage is a local contraindication, so avoid or apply light pressure over the affected areas while staying aware of patient positioning and comfort.

Pyloric Stenosis

• Congenital or acquired pyloric hypertrophy, resulting in blockage between the stomach and duodenum.
• The pylorus usually contracts to keep food in the stomach for digestion and relaxes to release food into the duodenum.
• Results in gastric outlet obstruction, and prevents the food from emptying out of the stomach.

Pyloric Stenosis Etiology

• Congenital is more common--congenital, idiopathic hypertrophy that becomes apparent within the first month of life. Could be due to genetics, or genetic and congenital conditions, and is 3-4x more common in males.
• Acquired pyloric hypertrophy is related to gastritis or peptic ulcers near the gastric antrum.

Pyloric Stenosis Signs and Symptoms

• Regurgitation.
• Persistent, projectile, nonbilious vomiting after feeding.
• May lead to dehydration and failure to thrive in infants.
• Infants often seem hungry and want to feed after vomiting.
• PE reveals visible peristalsis and a palpable, olive-sized mass.

Pyloric Stenosis Diagnosis and Treatment

• Abdominal ultrasound.
• Treatment involves surgical muscle splitting and pyloromyotomy.
• IV fluids are administered to correct dehydration.
• Massage is a local contraindication.

Acute Gastritis

• Transient, self-limiting inflammation of the gastric mucosa with neutrophilic infiltration.
• Characterized by hemorrhagic defects that extend through the entire thickness of the mucosa with sloughing of the superficial mucosa.

Acute Gastritis Etiology

• NSAIDs, H. pylori, Crohn's, alcohol use, and smoking.
• Emotional stress can cause it (although debatable).
• Severe stress to the body.
• Chronic intake of NSAIDs (decreases prostaglandins --> decrease mucous lining in the stomach).
• H. pylori prefers to live in the stomach and is linked to many other stomach diseases.

Acute Gastritis Signs and Symptoms

• Often no symptoms are present, but variable symptoms do occur.
• Common symptoms include epigastric pain/pressure, indigestion, and nausea/vomiting.
• Severe symptoms include overt hemorrhage, massive hematemesis (vomit blood), melena (blood in stool).
• Anemia and fatigue, weakness, and light-headedness.

Acute Gastritis Complications and Massage

• Complications include ulceration with significant bleeding, gastric perforation with peritonitis, and gastric atrophy leading to chronic gastritis.
• Local CI (avoid abdominal massage, as a patient with acute gastritis may need medical treatment depending on severity.)
• Postpone massage until recovered.

Chronic Gastritis

• Inflammation of the gastric mucosa with infiltration of lymphocytes and plasma cells. Associated with mucosal atrophy and intestinal metaplasia.
• Thinning (atrophy) of stomach lining leads to loss of many or all cells that produce acid and digestive enzymes.

Chronic Gastritis Etiology and Symptoms

• Caused by autoimmune and environmental causes.
• H. pylori is the most common environmental cause.
• Other examples include NSAIDs (aspirin), alcohol use, smoking, and Crohn's.
• Often asymptomatic.
• Common symptoms, if they occur – vague, mild dyspepsia (indigestion).
• Poor digestion and decreased protein breakdown if HCI secretion is reduced.
• Malabsorption.
• Pernicious anemia and polyneuropathies caused bylack of B12 absorption.

Chronic Gastritis Treatment and Massage

• Triple therapy is triple therapy, including PPIs (decrease stomach acid) and 2 antibiotics eliminate noxious substance and/or treat the cause.
• Local CI of avoiding abdominal massage.
• Patient with acute gastritis may need medical treatment depending on severity.
• Postpone massage until recovered.

Peptic Ulcer Disease (PUD)

• Sharply demarcated, round or oval ulcerations in the lining of the stomach or duodenum.
• Can be acute or chronic.
• Acute ulcers are usually shallow gastric lesions without a mounted immune response and are related to NSAIDs.

Anatomical Classifications of Peptic Ulcers

• Duodenal ulcers are the most common type, occurring in first few inches of unprotected duodenum because of gastric juice and digestive enzymes.
• Gastric ulcers typically occur along lesser curvature at the antrum stomach.
• Marginal ulcers occur where stomach has been surgically removed and anastomosed to intestine.

PUD Etiology and Symptoms

• An imbalance in gastroduodenal mucosal defense mechanisms and the damaging forces of HCI and pepsin in PUD. The most common cause is H. pylori. Present in 90% of people with duodenal ulcers and 75% of people with gastric ulcers.
• Other causes are NSAIDs, corticosteroids, severe stress, and smoking.
• Seventy percent of peptic ulcers are asymptomatic.
• Most common symptom is gnawing, burning, agonizing epigastric pain.
• Pain often waxes and wanes in periods of weeks or months.
• Other symptoms include hematemesis, bloating, and belching.
• Complications include iron-deficiency anemia, hemorrhage, or perforation
• Generally in children and elderly.

Gastric Ulcer Symptoms

• Symptoms occur in the gastric antrum or near the pylorus.
• Epigastric pain appears after eating.
• Weight loss because pain is worse with eating.
• Can have patients with early satiety. Can lead to gastric carcinoma.

Duodenal Ulcer Symptoms

• Occurs within the first few inches of the duodenum.
• Epigastric pain with emptying stomach. - Increased night pain because of increase acidic output at night. Decreased pain after eating weight gain.
• Pain occurs two to five hours post-meal.
• Cannot lead to gastric carcinoma.

PUD Complications

• Fistula: Burrowing through muscular wall of stomach or duodenum and continuing into an adjacent organ.
• Perforation: Occurs in 2 – 10% of PUD patients. Tearing through the anterior muscular wall of colon into the free space of the abdominal cavity.
• Suspect severe abdominal pain, radiating in the back, LUQ, chest that mimics cardiac pain. Classic perforation triad is sudden onset abdominal pain and tachycardia with abdominal rigidity and more common with gastric ulcers.
• BleedingHemorrhage of friable tissue. Hematemesis coffee grounds
• Melena or hematochezia. Scarring Cicatrization Healing of ulcerated tissue. Gastric outlet obstruction: Inflamed tissue around the ulcer swells

PUD Diagnosis and Treatment

• Related to characteristic abdominal pain. Test to confirm - endoscopy is safer; or barium is performed Barium really irritates the peritoneum. Treat or drugs ulcer relieve Do to not drug self heal ulcers.
• Discontinue any NSAIDs; antibiotics for H. pylori.
• Drug therapy is continued for 4-8 weeks.

Massage for PUD

• Massage is local contraindication - Avoid if it has abdominal discomfort If the patient has abdominal discomfort, it is best to avoid abdominal massage

Gastric Cancer

• Primary adenocarcinomas are in the glandular cells of the stomach. 95% of gastric cancers Epidemiology -50y old, eastern. More males

4000 diagnoses per year in Canada Common cancer 3rd mortality rare Related with smokers

Gastric Cancer Signs Symptoms & Diagnosis

• History of gastric ulcer or gastritis has abdominal pain or weight loos Best test w biopsy. Weight loss mc for tumors Metatatic node L Supraclavicular lymph Virchow's node

Gastric Cancer Prognosis

late diag so poor Prog Mass large. Survg - late dx bad 5+10% good to deep. Dued to large supply vasa and vessels

Treatment Massage

• Remove head lymph is primary may reiq cure+90%1 0% through 70+30% with disease Chemo and radiation limited Confort in position no contra

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IBD

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