Irritable Bowel Syndrome (IBS)

Irritable Bowel Syndrome (IBS) Definition

• IBS is a disorder of the intestine characterized by abnormal bowel motility.
• There is no damage to the intestinal lining or increased risk of colon cancer, unlike inflammatory bowel disease (IBD).
• It is a "functional" disorder involving impairment of the body's normal function, such as peristalsis, sensitivity of enteric nerves, or CNS digestive pathways; there is no structural involvement.

Irritable Bowel Syndrome (IBS) Epidemiology

• IBS affects approximately 15% of the population.
• Women are slightly more at risk.
• The condition usually begins in the mid-20s, with most cases starting prior to 35 years old.
• People with anxiety and/or depression are more likely to be affected.
• There is a suggested link between the gut and the brain, also known as the gut-brain axis.

Irritable Bowel Syndrome (IBS) Etiology

• The mechanism is generally unknown.
• Visceral hypersensitivity to various stimuli, such as certain foods or emotional stress, is a factor.
• Risk factors include previous gastroenteritis or food poisoning, as well as stress, anxiety, and depression, are risk factors.
• Triggers are inconsistent but may include diet (fatty/salty foods), eating too quickly or irregularly, as well as drugs and hormones.

Irritable Bowel Syndrome (IBS) Signs and Symptoms

• Colicky, lower abdominal pain that is relieved with defecation is a sign.
• Changes in frequency and consistency of bowel movements, including constipation (IBS-C), diarrhea (IBS-D) or both (IBS-M, mixed) are symptoms.
• Other signs include bloating and distension of abdomen, a sensation of incomplete emptying after bowel movements, and mucus in stool.
• Systemic symptoms may include nausea, headaches, fatigue, anxiety, depression, and difficulty concentrating.

Bristol Stool Chart and IBS

• A medical aid designed to classify stools, is used in diagnosis.
• Types 1 and 2 indicate constipation.
• Types 3 and 4 are considered normal.
• Type 5 may or may not be normal.
• Types 6 and 7 indicate diarrhea.

Irritable Bowel Syndrome (IBS) Diagnosis

• Diagnosis is symptom-based. Physical examination (PE) is usually within normal limits (WNL), except for potential tenderness with colon palpation
• Blood tests, stool samples, and colonoscopy are used to rule out more serious conditions, such as IBD, ulcers, or cancer.
• Indications for referral include consistent rectal bleeding, weight loss, unexplained iron-deficiency anemia (IDA) and a family history of colorectal cancer.

Irritable Bowel Syndrome (IBS) Treatment

• Varies depending on triggers and presentation.
• Identify and eliminate triggers, whether that is food or emotional stress.
• IBS-D may require antidiarrheals.
• IBS-C may require laxatives or increased fiber to regulate bowels.
• Increasing physical activity, stress, anxiety, and depression management (including anxiolytic and antidepressant medications) are treatments.
• Research on the treatment of irritable bowel syndrome with probiotics is mixed

Irritable Bowel Syndrome (IBS) Triggers and FODMAPS

• Common triggers include fatty foods, fried foods, highly processed foods and some of the foods in the chart.
• Dairy and gluten may be fine for many people not suffering from lactose intolerance or gluten allergy/sensitivity.
• FODMAPS are fermentable oligosaccharides, disaccharides, monosaccharides and polyols

IBD vs. IBS

• IBS can affect quality of life but is not life threatening, surgery is never indicated, and there is no increased risk of colorectal cancer
• IBD UC-13.9 or CD-8.3 per 100,000, requires continuous monitoring, increased risk of colorectal cancer, and surgery needed for some.

Massage for Irritable Bowel Syndrome (IBS)

• Be mindful of a LOCAL CONTRAINDICATION
• Avoid the abdomen during massage if it causes patient discomfort.

Diverticulosis Definition

• Diverticula are balloon-like pouches that can form along the wall of any hollow structure in the body.
• True diverticula include all four layers of the intestinal wall (mucosa to serosa).
• Pseudodiverticula include mucosa and submucosa that poke through and past the muscle layer, and are covered only by serosa (more common).
• The most commonly affected area is the sigmoid colon
• Affects areas where vessels traverse muscle layer .i.e. where the vasa recta penetrate the circular muscle layer of the colon

Diverticulosis Epidemiology

• Prevalence is age dependent; there is an increased risk with increased age.
• Less than 10% of the cases are younger than 40. Twenty percent are at age 40, while sixty percent are at age 60.
• Most patients are older than 50 years; the mean age at presentation appears to be about 60 years.

Diverticulosis Etiology

• High pressure in the lumen is the cause.
• Low fiber diets and constipation potentially contribute.
• Theories include that smooth muscle contractions are exaggerated and abnormal.
• Mechanism for abnormal contractions/spasms is unclear.
• Can be caused by Genetic CT disorders like Marfan and Ehlers Danlos syndromes.

Diverticulosis Signs and Symptoms

• Usually asymptomatic unless complications occur.
• Often, it is discovered incidentally on colonoscopy.
• When symptomatic, vague abdominal pain and BM irregularity may occur.

Diverticulosis. Complications

• If the diverticula worsens or gets infected it can cause various complications such as:
• Occurence of Diverticulitis (1-4% of patients)
• Diverticular bleeding (5-15% of patients)
• Fistula

Diverticulosis Complications: Diverticulitis

• It is inflammation of an infected diverticula
• Diverticulitis is often due to impacted fecal matter and associated colonic bacteria and may result in perforation and peritonitis.
• Symptoms include LLQ pain, constant fever, perhaps palpable mass in LLQ due to inflammation, abdominal guarding, rigidity, and tenderness.
• Hematochezia is RARE in acute diverticulitis flares.

Diverticulosis. Complications: Diverticular Bleeding

• As a diverticulum herniates, the penetrating vessel responsible for the wall weakness becomes draped over the dome of the diverticulum, and is susceptible to bleeding.
• Diverticular bleeding typically occurs independent of diverticulitis.

Diverticulosis Diagnosis

• A General Practitioner (GP) suspects the condition based on signs and symptoms (SSx), which is confirmed by colonoscopy or barium x-ray.
• Colonoscopy is used when bleeding is present, as it is the best way to determine the source.
• Computerized Tomography (CT) can be performed if severe pain is present.

Diverticulosis Treatment

-A reduction of pressure and spasms is the aim - High fiber diet and increased fluid intake will aid

• Uncomplicated bleeding is self-limiting and does not require treatment (Tx).
  • If bleeding continues, curettage is performed during colonoscopy
  • Recurrent bleeding may require colectomy.
• Diverticulitis is treated (Tx) with antibiotics to limit bacterial overgrowth

Massage for Diverticulosis

• Possible LOCAL CONTRAINDICATION
• Avoid massaging the abdomen, if it causes the patient discomfort.
• For patients with diverticulitis, avoid massage until the condition has been treated.

Hemorrhoids Definition

• Hemorrhoids are swollen blood vessels located in the anal canal (internal hemorrhoids) or around the anus (external hemorrhoids).
• It is a very common condition, as nearly 3 out of 4 adults will have hemorrhoids in their lifetime.

Hemorrhoids Etiology

• Hemorrhoids can be caused by prolonged pressure on the anus, including prolonged sitting, pregnancy, childbirth, or obesity.
• Other causes are constipation and/or diarrhea and accompanying straining (i.e., IBS), low-fiber diet, and advanced age

Hemorrhoids Signs and Symptoms

• Internal hemorrhoids often cause rectal bleeding with minimal pain. Symptoms of bright red blood appearing in the stool is a sign.
• External hemorrhoids can fill with blood, enlarge, and cause discomfort as well as itching or bleeding.

Hemorrhoids Diagnosis

• Diagnosed via digital rectal exam (DRE) or visual inspection.

Hemorrhoids Treatment

• Conservative treatment is often curative and includes eating high-fiber foods and using topical treatments
  • Topical treatments include witch hazel, corticosteroids, phenylephrine, or lidocaine.
  • Preparation H combines various of the above ingredients.
  • Phenylephrine is a sympathomimetic that vasoconstricts blood vessels.
• Regular warm baths or sitz baths, along with analgesics by mouth are treatments
• Surgical removal may be necessary if these treatments do not bring improvement or relief.

Massage and Hemorrhoids

• No contraindications.
• Be cautious of patient positioning and comfort.

Appendicitis Definition

• Appendicitis is the inflammation of the vermiform appendix.
• The most common surgical emergency of the abdomen which affects 10% of the population.
• The incidence is highest in the 10-19 year old age group.

Appendicitis Etiology

• Obstruction is the primary cause.
• It includes Fecolith, fibrosis, parasite infection, and lymphoid hyperplasia (in children).

Appendicitis Signs and Symptoms

• First symptom is periumbilical pain often with nausea, vomiting and anorexia
• Pain will often shift to the RLQ region with nausea
• Positive McBurney's sign, Rovsing's sign, psoas sign, obturator signs, positive rebound tenderness and abdominal guarding
• Low-grade fever is another symptom
• Children commonly have more vague pain patterns as do pregnant women and elderly have milder tenderness

Appendicitis: Physical Exams

• McBurney's sign indicates when significant pain is elicited by palpating the RLQ
• Rovsing's sign means that there is tenderness in the RLQ
• Psoas sign can indicate the obstruction, is when pain is elicited during hip extension
• Obturator sign is when retrocecal or pelvic appenditicitis is suspected.
• Be sure to assess for abdominal guarding

Appendicitis Complications

• Major complication is Rupture/Perforation
• Increased risk of rupture/perforation is seen with increasing age, and in males.
• Perforation can lead to abscess formation and intra-abdominal infection, as well as sepsis
• Initial relief of pain will ensue before a high fever and peritonitis

Appendicitis Diagnosis

• Appendicitis is suspected on History (Hx) and Physical Examination (PE).
• Will see increased White Blood Cell count (WBC) on Complete Blood Count ( CBC/blood tests
• A CT scan (CT) or Ultrasound (US) may be performed.
• An Exploratory laparoscopic surgery may be performed to confirm.
  • Appendix is often removed even if it is not inflamed

Appendicitis Treatment

• A appendectomy by way of surgery is required to remove the problematic appendix
• Intravenous (IV) antibiotics will be needed post surgery

Massage and Appendicitis

• Is an absolute contraindication due to the need of an immediate medical assessment

Peritonitis Definition

• Peritonitis is inflammation of the inner membrane that lines the abdominal cavity and abdominal organs.
• The inner membrane is also known as the peritoneum.
• Most commonly caused by secondary infection.

Peritonitis Types

Classified based on etiology

• Spontaneous Bacterial Peritonitis or (SBP; aka primary) is the development of ascitic fluid infection without an evident intra-abdominal infection
• Complication of advanced cirrhosis.
• Secondary Peritonitis is much more common than SBP.
  • Can develop with the infectious diseases of intra-abdominal organs as it spreads to the peritoneum
• Secondary Peritonitis: The Infectious disease of intra-abdominal organs spreads to the peritoneum; often occurs as a complication of ruptured organs in abdomen such as appendicitis, pancreatitis, peptic ulcer disease, perforated colon/diverticula

Peritonitis Signs and Symptoms

• Fever, nausea, vomiting, chills, sudden, severe abdominal pain worse with movement, abdominal tenderness
• Dehydration, electrolyte imbalances, and sepsis commonly seen.

###Treatment for Peritonitis

• Surgery to remove infected tissue or drain fluid
• IV antibiotics, and pain medications

Massage and Peritonitis

• Is an ABSOLUTE CONTRAINDICATION because Peritonitis is a medical emergency that requires immediate medical attention.

Viral Gastroenteritis

• Is a viral infection of intestine that cause nausea, vomiting, and watery diarrhea
• Common name is "stomach flu”.
• Rotavirus is the most common cause of diarrhea in children under 2 years old.
  • Easily spead via fecal-oral route
• Immunity develops and each subsequent infection is less intense and rare in adults.
• Norwalk virus occurs in small epidemics and usually heals without consequence
  • Often Spread fecal-oral route or person-to-person contact, and/or air droplets of vomited virus

Bacterial Gastroenteritis

• Bacterial Gastroenteritis is loose stools caused by various bacterial infections where the bacteria invade and colonize intestine, then cause inflammation and destroy tissue -Bacterial toxins (pre-formed in food then, ingested or released by bacteria growing outside the intestine)
• S aureus or e. Coli or food poisoning caused by unrefrigerated/contaminated food (Lytic bacteria, enterotoxigenic bacteria enter colon and destroy tissue)
• Clostridium botulinum: Botulism caused by canned food
• Enterotoxigenic bacteria in colon: E coli (Traveller’s diarrhea or enterocolitis)
• Invasive bacteria: produce intestinal inflammation, ulcerations, bleeding and/or perforation Shigella and Salmonella - Can enter blood and lymphatics to cause systemic infection

Protozoal Enteritis

Protozoal Enteritis is a result of parasitic infections of the intestine

• Common to come down with following travel to southern countries:
  • Giardia lambia ("Beaver Fever”):infection of small intestine caused by contaminated water:
    • Causes diarreha and/or malabsorption
  • Entamoeba histolytica: anaerobic ameba in tropical locations, infects travellers more than local residents - Usually asymptomatic carriers, pass parasite unknowingly, 10 % People have tissue destruction with parasitic metabolism resulting in ulceration

Massage with Infectious Disease Precautions

• Infections disease are a contraindication and Clients should not be in your office if they are feeling unwell.

Intestinal Ischemia Definition

• Is a group of disorders that result from comprised blood flow in segments of the intestine (can affect LI or SI) A process that reduces intestinal blood flow: - Atherosclerosis
  • Emboli/thrombi of various intestinal arteries
  • Arterial vasospasm
  • Acute: sudden onset and associated with high mortality -Chronic: mild and non-specific sxs that are often goes undiagnosed

Intestinal Ischemia: Ischemic Colitis

• In ischemic colitis blood flow to part of the colon is slowed or blocked by: - Hypotension, Shock or Severe dehydration, atherosclerosis, thrombosis, volvulus or incarceration.

Intestinal Ischemia: Acute MI

• In acute MI one may experience the sudden onset (etiology) of small intestinal hypoperfusion with the follow: - Arterial embolism brought on by chronic heart failure (CHF) arryhthmia or MI - Usually with a medial cause of acute mesenteric ischemia (atherosclerosis or thrombosis) - Can also be caused by decresed blood flow from low cardiac output, chronic heart failure or kidney failure

Intestinal Ischemia SIgns and Symptoms

• Sudden, severe abdominal pain out of proportion of physical exam
  • Nausea/vomiting, peritonitis, and increasing tenderness over the course of ischemia
  • Lack of flood flow over 10 hours causes intestinal necrosis - Bacteria can invade system and cause organ failure or septic shock.

Intestinal Ischemia Diagnosis

• Diagnosis will depend on clinical suspicion, especially if related to those patients with RFs for peripheral embolization or those with a heart condition.
  • Angiography can be another indicator.

Intestinal Ischemia: Treatment and Prognosis

• TPA hemolytic agents during angiography, can be used during immediate surgery if needed to address obstructed vessels.
  • Long term Use of post operative anticoagulants, which could prevent future bouts of blood clots.
• Early diagnosis can allow full recovery, while advavced ischemia will require bowel resection which can cause a 15x increase in mortality.

###Massage with Intestinal ischemia

• Absolutely contraindicated since this condition is a medical emergency and requires immediate medical attention.

Intestinal Atresia

Definition: congenital, complete obstruction of intestinal lumen Presentation: Abdominal distention Treatment: Surgical resection with anastomosis of uninvolved segments

Massage for Intestinal Atresia

• Not Applicable Will be treated within first few days of life.

Definition of MecKel's Diverticulum

• Meckel's Diverticulum is a congenital outpouching of intestine due to a remnant of embryonic connection between intestine and umbilicus, usually an appendage of ileum
• Its is the most common malformation of GI tract but can be Asymptomatic or undiagnosed with infected/or rupture

Meckel's Diverticulum Signs and Symptoms

• Usually asymptomatic however with with
  • Rectal bleeding or pain in the epigastric and the lower left quadrant of the abdomen

Meckel's Diverticulum - Complications and Treatment

• Complications: Intestinal obstruction, volvulus, and or intussusception
• Treatment: Surgical Removal

MecKel's Diverticulum - Rules of 2's

• 2% of the population are diagnosed. -The male to female ratio is 2:1
• That will be located 2 feet from ileocecal valve with the length of 2inches -2% will develop complications (at the age of 2)

Massage for Meckel's Diverticulum

Be mindful of a LOCAL CONTRAINDICATION

Hirschsprung's Disease Definition

• Is a congenital disorder where part of the intestine has a lack of interrvation and missing nerve networks which result in dysfunction or lack of peristalsis.

Hirschsprung's SAigns and Symptoms

• The Failure to pass meconium within the first 48 hours , with bilious vomiting and abdominal distension

Hirschsprung's Complications and

• Megacolon and intestinal obstruction
• Treatment (temporary colostomy) and long with high high fibre and or laxatives

Massage for Hirschsprung's disease

Is a local contraindication

Intussusception Definition

• Intussusception is a.k.a telescoping, where an intestinal disorder in which a segment of the intestine folds in on itself which include bowel obstruction and vascular blockage leading to:
• Most commonly occurs in ileocecal region

Intussusception facts

-Its the Obstruction of the intestine by leading to a large or small Intestinal obstruction

• Its most common in children 3 years since it is an abnormality in the gut or tumor

Intussusception Etiology

• Risk for children are Idiophatic but Meckel's diverticulum and Hirschsprung's disease:
• Other risks can be fromIntestinal malrotation, family history and a possible polyp or tumor can be caused by an abdominal Intermittent abdominal pain and Palpable mass

###Intussusception Complications

• Complications lead to bowel obstruction or perforation, and may be associated with a number of intestinal insults
• Causing Ischemia leading to: Sloughing of tissue, results in blood and mucus in stool Peritonitis from severe inflammation

Intussusception Diagnosis

• Diagnosis is conducted through abdominal exams of CT scans that demonstrate a bullseye formation of the abdominal muscle

Intussesception: Treatment

• The treatment consists of fluid or air in the bowel wall, followed an infantile procedure for adults to clear the obstructions for adults

Intussusception and Message

Since the condition is serious massage and immediate Medical treatments is needed for intussesception

Volvulus Definition and Etiology

• Volvulus is a twisting loop of intestine around itself and its surrounding mesentery that causes serious complications like bowel obstruction, perforation and blockages or ischemia Can cause blockages or obstruction
• Mainly pregnancy may cause twists of the colon intestine and with an abdominal adhesions as caused by birth and injury
• This effect will only be seen by those with high levels in the abdominal area

Volvulus Presentation

• Presents as an Abdominal distention and severe Pain will show a Bloody stole or constipated, bloody

Volvulus Diagnosis and treatment options

• X-Ray will be performed in the area especially with barium testing
• tubes an be installed and can allow you to return bowel functions and reduce future problems.

Volvulus Treatments

• Treatment is performed with Tubes able to relieve pressure and untwist and may need to be removed or adjusted in the near future

Treatment for volvulus

• Absolutely contraindicated as it requires an immediate treatment to prevent serious damage to the bowel

Strangulation Definition and Etiology

Strangulation is a process that can cause tissue damage due to lack of bowel function, but can be caused by a twist.

• The main causes are :bowel obstructions, hernias, and volvus
• Sign and Symptoms include: Severe Pain with a fever, gangrene, or perforation

Strangulation complications

Gangrene can occur six hours , or peritonitis may be fatal if not treated.

Massage for Stranguation

Is also considered absolutely contraindicated since it may call for a medical need during the time of massage

Familial Adenomatous Polyposis (FAP)

FAP is an Autosomal dominant disease causing polyps that result in colon cancer with in the first 40 years of life.

• About 50% by the age 15 will lead to polyps
• While 95% may lead to cancer in one's life

Familial Signs and Symptoms

• The signs are asymptomatic or may cause rectal bleeding or lead to colon cancer

Familial Diagnosis

The diagnosis of FAP requires for a Stool test or a Colonoscopy to identify genetic mutations ,and test for first degree relatives

FAPTreatment

Requires an Colectomy and screening of the anal cavity

FAP and massage

Since one is not in pain , massage should be considered to continue

Colorectal Carcinoma Definition

• Colorectal Carcinoma is related to glandular intestinal lining and the early metastasis leads to poor organ function
• Usually begins with a Benign polyp-like tumor (that can cause obstruction)
• Is caused by rapid lymphatic growth near organs
• The high rate of vascular growth leads to poor liver function which is common in late years

Colorectal Carcinoma and Epidemiology

• Overall leading cancer in world but in western countries
• Slight more common in males than females
• One in every 16 males are likely to colon as well as One out 18 females
• Women face Colon Cancer while men may tend to see Rectal cancer

Colorectal Sign and Symptoms

• Slow growth with early stage sign
• Most signs do not come until late stages
• Blood will be noted in stool
• Change in bowel habit which may be a more frequent diarrhea or constipation ,
• This can be caused also due to a obstruction that make one face bloating or stomach discomfort.

Colorectal Diagnosis and Treatment

• Most Screening will show colorectal areas
• Screening will be performed over 50 and Fecal testing will be used in stool to analyze rates and can be performed every 2 years to test for risks
• If any problems are located the polyp removed and sent to pathology for analysis
• Stool will contain Blood where positive tests may need further Colonoscopy
• Analysis tests and abdominal tests will be performed for more tests or other tests

###Treatment for Colorectal Disease Surgical removal is required and this is conducted primary

• The bowel will face a 90% cure when lining is affected with bowel is at 705 or drops with high stage -A temporary surgery May be used before the procedure
• Most tests rely on high levels (FYI)- the deeper the tumor the higher the morality goes out -0-4 stages, but some cases have different stage.

###Massage and treatment for Coloractel Cancer There are No contraindications for testing since patients are not in pain nor in discomfort