Digestive Path Lecture 1 PDF

Diseases of the Gastrointestinal System Part 1 Lecture Outline: Disorders of the Esophagus Disorders of the Stomach IBD (Crohn’s/UC) Celiac Disease Malabsorption Syndrome...

Diseases of the Gastrointestinal System Part 1 Lecture Outline: Disorders of the Esophagus Disorders of the Stomach IBD (Crohn’s/UC) Celiac Disease Malabsorption Syndrome Dr. Kevin Tipper, ND DISORDERS OF THE ESOPHAGUS Hiatal hernia, GERD Hiatal Hernia Definition A protrusion of a portion of the stomach through the esophageal hiatus Affects ~15% of the population; possible it rises to ~60% for persons 60+ Very few have symptoms, and even fewer require treatment or surgery Presentation: minor to severe reflux indigestion, bloating, and/or dysphagia Hiatal Hernia Etiology Unknown causes for most hiatal hernias, however there are certain things that increase risk: Age-related changes in your diaphragm (>50, progressive weakness) Injury to the area, for example, after trauma or certain types of surgery Being born with a very large hiatus Constant and intense pressure on the surrounding muscles. This can happen while coughing, vomiting, straining during a bowel movement, exercising or lifting heavy objects. Obesity Hiatal Hernia Types of Hiatal Hernia Thereare two types of hiatal hernias, categorized by what portion of the stomach bulges through the diaphragm 1. Sliding Hernia (Type I): 95% 2. Paraesophageal Hernia (Type II): 5% Hiatal Hernia Types of Hiatal Hernia Sliding Hernia (Type I) protrusion of the LES and gastroesophageal junction through the diaphragm Creates bell-shaped dilation d/t constriction of LES about and constriction of diaphragmatic narrowing below Hiatal Hernia Types of Hiatal Hernia Paraesophageal Hernia (Type II) fixed protrusion of a separate portion of the stomach into the thorax LES and gastroesophageal junction remain below the diaphragm, while herniated portion is beside the esophagus Hiatal Hernia Hiatal Hernia Signs and Symptoms Most sliding hernias are asymptomatic or have minor SSx MC SSx indigestion, especially if laying after eating May have dull chest pain, SOB, heart palpitations Increased w/ trunk flexion, straining, heavy lifting, and pregnancy Can lead to incarceration, especially paraesophageal hernias Microscopic or massive bleeding in either type is rare Hiatal Hernia Complications Strangulation= painful and emergent complication of paraesophageal hernias Stomach pinched by diaphragm and loses blood supply SSx: chest pain, bloating, belching, and dysphagia Hiatal Hernia Diagnosis Barium x-ray Treatment Most sliding hernias do not require treatment Lifestyle changes: raising head of bed, eating small meals/not eating before sleep, weight loss, smoking cessation, looser clothing Eliminate cola, acidic juices, alcohol, coffee, and spicy/fatty foods Rx: H2 blockers or PPI Paraesophageal hernias that cause SSx should be surgically repaired to prevent strangulation Hiatal Hernia Massage and Hiatal Hernia LOCAL CONTRAINDICATION Avoid or only light pressure over effective area Be conscious of patient positioning and comfort Gastroesophageal Reflux Disease (GERD) Definition Backflow of stomach acid and enzymes from the stomach into the esophagus, causing esophageal inflammation (called reflux esophagitis) Stomach lining includes mucus secreting cells to protect from acid Esophagus lacks protective lining Acid causes inflammation and eventually erosion Gastroesophageal Reflux Disease (GERD) Etiology Malfunction of LES permits stomach contents into esophagus Risk factors: hiatal hernia, obesity, pregnancy, fatty foods, chocolate, caffeinated and carbonated drinks, alcohol, smoking, certain drugs Anticholinergic drugs, calcium channel blockers, progesterone, and nitrates may interfere with LES fxn Gastroesophageal Reflux Disease (GERD) Signs and Symptoms MC SSx: heartburn and regurgitation Occasionally pain extends to neck, throat, and face OtherSSx: sore throat, hoarseness, excessive salivation, sensation of lump in throat, dry cough Slight or massive bleeding d/t inflammation Vomited or passed as black, tarry stool (melena) Gastroesophageal Reflux Disease (GERD) Complications Esophageal ulcers d/t chronic reflux (present like heartburn) Stricture d/t chronic ulceration dysphagia, SOB, and wheezing Barrett’s esophagus: metaplastic changes d/t acid irritation Changes may occur even in the absence of symptoms Gastroesophageal Reflux Disease (GERD) GERDcomplication: Barrett’s esophagus Switch of cell type from stratified squamous epithelium to columnar Why? Gastroesophageal Reflux Disease (GERD) Diagnosis Based on SSx; no diagnostic tests needed to start treatment Special testing available when Dx is unclear or when treatment has failed to control sx Endoscope, x-ray studies, pressure measurement of LES, and esophageal pH testing Treatment Lifestyle changes: similar to changes for hernias Eating habits, remove irritating foods, etc. Parasympathetic stimulators to tightly close LES H2 (histamine-2 receptor) blockers or PPIs (proton pump inhibitors) to reduce acid Gastroesophageal Reflux Disease (GERD) Massage and Gastroesophageal Reflux Disease (GERD) No contraindications Bemindful of patient positioning and timing of massage DISORDERS OF THE STOMACH Diaphragmatic hernia, Pyloric stenosis, Gastritis, Peptic Ulceration, Gastric cancer Diaphragmatic Hernia Definition protrusionof organs into the thoracic cavity through a weakening in the diaphragm (that’s not the esophageal hiatus) Stomach and/or intestines push through weakened opening Diaphragmatic Hernia Etiology Congenital: d/t embryologic defect of diaphragm (affected neonates usually present in the first few hours of life w respiratory distress) Acquired: MC cause is blunt force trauma (diaphragm usually injured in association w other thoracic and abdominal organs) Diaphragmatic Hernia Congenital Diaphragmatic Hernia Diaphragmatic Hernia Signs and Symptoms abdominal pain decreased breath sounds SOB auscultation of bowel sounds in chest potential bulge Nearly half of adults don’t have any SSx Diaphragmatic Hernia Complications Incarceration of organs Incarceration can cause strangulation Strangulation can lead to perforation and peritonitis Surgical emergency Treatment Congenital: surgical repair within 24-48 hours Acquired: surgical repair as soon as patient presents with symptoms Prognosis Recurrence possibly, but rare Routine check-ups w/ CXR and PFTs Diaphragmatic Hernia Massage and Diaphragmatic Hernia LOCAL CONTRAINDICATION Avoid or only light pressure over effective area Be conscious of patient positioning and comfort Pyloric Stenosis Definition Congenital or acquired pyloric hypertrophy resulting in blockage of passageway between stomach and duodenum Pylorus fxn: contracts to keep food in stomach for digestion and relaxes to release food into duodenum Results in gastric outlet obstruction - prevents stomach from emptying into SI and food backs up into esophagus Pyloric Stenosis Pyloric Stenosis Etiology Congenital (more common): congenital, idiopathic hypertrophy that becomes apparent w/in first month of life Possible genetic component Linked to other genetic and congenital conditions: Turner syndrome, trisomy 18, and esophageal atresia 3-4x more common in males Acquired: pyloric hypertrophy related to gastritis or peptic ulcers near gastric antrum Pyloric Stenosis Signs and Symptoms Regurgitation Persistent, projectile, nonbilious vomiting after feeding (projectile vomiting) Can lead to dehydration and FTT in infants Common to have infants seem hungry and want to feed again after they vomit PE reveals visible peristalsis and palpable, olive sized mass Diagnosis Abdominal US Treatment Surgical muscle splitting (pyloromyotomy) IV fluids to correct dehydration Pyloric Stenosis Massage and Pyloric Stenosis LOCAL CONTRAINDICATION Acute Gastritis Definition aka Erosive 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 w/ sloughing of the superficial mucosa Acute Gastritis Etiology MCcauses: NSAIDs (aspirin), H. pylori, EtOH, smoking, and Crohn’s Emotional stress Increased acid production and decreased mucous production Severe stress to the body Illness or injury w/ severe burns or bleeding Results in ischemia of mucosal lining Acute Gastritis Signs and Symptoms Often there are no SSx, but are variable if they do occur Common SSx: epigastric pain/pressure, indigestion, nausea/vomiting Severe SSx: overt hemorrhage, massive hematemesis, melena Anemia w/ fatigue, weakness, and light-headedness Complications Ulceration w/ significant bleeding Gastric perforation w/ peritonitis Gastric atrophy leading to chronic gastritis Chronic Gastritis Definition Inflammation of the gastric mucosa w/ infiltration of lymphocytes and plasma cells and 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 Etiology Subtypes: autoimmune & environmental H. pylori is MC environmental cause Other examples: NSAIDS (aspirin), EtOH, smoking, Crohn’s Chronic Gastritis Signs and Symptoms Most often asymptomatic Common SSx, if they occur: vague, mild dyspepsia Poor digestion and decreased protein breakdown if HCl secretion is reduced Malabsorption Pernicious anemia and polyneuropathies d/t lack of B12 absorption Why? Chronic Gastritis Treatment Discontinue and avoid drugs that can aggravate gastritis (aspirin, NSAIDs) Eradicate H. pylori Triple therapy PPIs and 2 antibiotics Gastritis Acute v. Chronic Gastritis Acute Gastritis Chronic Gastritis Onset Abrupt Gradual Duration 1 day – 6 months > 6 months Immune Acute inflammatory cells Chronic inflammatory cells Reaction – Neutrophils – Lymphocytes & plasma cells Etiology H. pylori, alcohol, H. pylori, autoimmune NSAIDS, severe stress Symptoms Dyspepsia, N/V, Dyspepsia, malabsorption, hemorrhage, pernicious anemia hematemesis Gastritis Massage and Gastritis LOCAL CONTRAINDICATION Avoid abdominal massage Patients with acute gastritis may need medical treatment depending on severity Postpone massage until recovered Peptic Ulcer Disease (PUD) Definition sharply demarcated, round or oval ulcerations in the lining of the stomach or duodenum Can be Acute or Chronic Acute usually shallow gastric lesions w/o mounted immune response and are related to NSAIDs Peptic Ulcer Disease (PUD) Anatomic classifications Duodenal: most common type, occurs in first few inches of unprotected duodenum d/t gastric juice and digestive enzymes Gastric: typically occur along lesser curvature at the antrum stomach Marginal: occur where stomach has been surgically removed and anastomosed to intestine Peptic Ulcer Disease (PUD) Etiology Imbalancein gastroduodenal mucosal defense mechanisms and damaging forces (HCl and pepsin) MC cause: H. pylori Present in 90% of people w/ duodenal ulcers and 75% of people w/ gastric ulcers Other causes: NSAIDs, corticosteroids, severe stress, smoking Peptic Ulcer Disease (PUD) Signs and Symptoms ~70% of peptic ulcers are ASx MC SSx: Gnawing, burning, aching epigastric pain Pain often waxes and wanes (in periods of weeks or months) Other SSx: hematemesis, bloating, belching Complications include: iron-deficiency anemia, hemorrhage, or perforation (usually in children and elderly) Peptic Ulcer Disease (PUD) Gastric Duodenal Gastric v. Duodenal Gastric antrum or near pylorus First few inches of duodenum Symptoms Epigastric pain after eating – due to Epigastric pain w/ empty stomach visceral sensitization and gastroduodenal dysmotility -Pain worse with eating (possible -Increased night pain d/t increased weight loss) acid output at night (11pm-2am) -Postprandial belching and -Decreased pain shortly after eating epigastric fullness (possible weight gain) -Early satiety -Pain occurs 2-5hrs post meal when acid is secreted in the absence of a food buffer Hematemesis or melena Hematemesis or melena GERD may coexist but may or may GERD may coexist but may or may not be related to peptic ulcers not be related to peptic ulcers Can lead to gastric carcinoma Cannot lead to gastric carcinoma Peptic Ulcer Disease (PUD) Complications Fistula borrowing through muscular wall of stomach or duodenum and continuing into an adjacent organ (fistula) Perforation (occurs in 2-10% of PUD pt) tearing through anterior muscular wall of organ into the free space of the abdominal cavity Suspect in those who develop sudden, diffuse, severe abdominal pain that radiates in back, LUQ, and/or chest (may mimic cardiac pain) Classic perforation triad = sudden onset abdominal pain + tachycardia + abdominal rigidity More common w/ gastric ulcers Bleeding hemorrhage of friable tissue Hematemesis that can be bright red or reddish brown clumps (coffee ground) of partially digested blood ~10% mortality rate Melena or hematochezia Peptic Ulcer Disease (PUD) Complications Excessive scarring (cicatrization) healing of ulcerated tissue Gastric outlet obstruction inflamed tissue around ulcer swells or scars and narrows pyloric antrum Can occur with ulcer located in pyloric channel or duodenum Early satiety, epigastric pain shortly after eating, persistent projectile vomiting Cancer related to ulcers caused by H. pylori Risk is increased 3-6x Peptic Ulcer Disease (PUD) Diagnosis Suspicion related to characteristic abdominal pain Tests may be needed to confirm: endoscopy or barium x-ray Used when tx fails to resolve SSx Used when pt is >45yo and has SSx of weight loss (r/o gastric CA) Treatment Discontinue any NSAID use or any other irritants Antibiotics for H. pylori infection Neutralize or reduce stomach acid w/ OTC or Rx drugs while ulcer heals Do not themselves heal ulcers, but relieve SSx and raise pH of stomach Take for 4-8 weeks Peptic Ulcer Disease (PUD) Massage and Peptic Ulcer Disease (PUD) LOCAL CONTRAINDICATION Ifthe patient has abdominal discomfort, it is best to avoid abdominal massage Gastric Cancer Definition primary adenocarcinomas from glandular cells of the stomach 95% of gastric cancers are primary adenocarcinomas Epidemiology Most common populations: > 50 years old, eastern Asia has the highest incidence, Africa has the lowest More common in males > 4000 diagnoses per year in Canada 5th most common cancer, 3rd highest mortality rate worldwide Gastric Cancer Etiology Risk factors: H. pylori infection Large or multiple gastric polyps (discussed next class) Potential dietary link (smoked, salted, pickled food, nitrates) Smoking and obesity MajorRF for gastric cancer is H. pylori infection w/ sustained inflammation of gastric lining Gastric Cancer Signs and Symptoms Early SSx are vague and may mimic burning pain and early satiety of peptic ulcers R/o gastric CA if tx of peptic ulcers do not resolve SSx SSx include: Weight loss (MC) – results from insufficient caloric intake d/t nausea, pain, early satiety Abdo pain – when present, epigastric and mild Nausea – usually a result of the tumor mass itself that disrupts ability of stomach to distend Dysphagia – more common with CA arising at gastroesophageal junction Melena, early satiety, ulcer type pain MC PE finding of metastatic dz is enlarged L supraclavicular lymph node (Virchow’s node) Gastric Cancer Diagnosis Suspect dx in pt with abdominal pain, weight loss and Hx of gastric ulcer or chronic gastritis Best test: upper endoscopy w/ biopsy Prognosis Five year survival rate is 10% Late diagnosis w/ metastatic disease Prognosis is better if CA has not penetrated too deeply Early metastasis d/t vast supply of lymph vessels and nodes Treatment Surgical excision of large portion of stomach and local lymph nodes May be palliative to eliminate obstruction and allow food to pass Chemotherapy and radiation have limited effectiveness beyond palliative care Gastric Cancer Massage and Gastric Cancer No contraindications Beaware of patient comfort in certain positions DISORDERS OF THE INTESTINES Celiac disease, Inflammatory bowel disease (IBD, Crohn’s and UC), Malabsorption Syndrome Celiac Disease Definition Aka celiac sprue, non-tropical sprue, gluten enteropathy Immune disorder triggered by an environmental agent (gluten) in genetically predisposed individual Gluten: a protein found in wheat, barley, and oats Genetic component in 10% of cases Pathophysiology Immune response to gluten ingestion causes inflammation and flattening of villi in small intestine that results in malabsorption Celiac Disease Etiology Risk Factors: Having 1st or 2nd degree relatives with celiac (genetic component) Often associated with other autoimmune diseases Type 1 DM Autoimmune thyroiditis Down’s Syndrome and Turner Syndrome Celiac Disease Signs and Symptoms SSx depend on severity of damage to small intestine GI SSx chronic diarrhea (foul smelling stools), bloating, malnutrition, weight loss Malabsorption syndromes and resultant symptoms. Common deficiencies include: Iron: anemia w/ fatigue and weakness Calcium & Vit D: osteopenia, tooth decay, and higher risk of fractures B12: pernicious anemia, extremity paresthesia Protein: fluid retention and edema Extraintestinal SSx: Dermatitis Herpetiformis: multiple pruritic papules and vesicles in grouped arrangements (MC sites are elbows, dorsal forearms, knees, scalp, back, and buttock) Celiac Disease Celiac Disease Diagnosis SSx raise suspicion and are followed up with blood or stool Ab-Ag tests Dx confirmed w/ biopsy Treatment Gluten free diet Corticosteroids Prognosis Potential risk for developing intestinal lymphoma and GI CA Unknown if GF diet decreases risk Small absolute increase in overall mortality in patients with celiac disease compared with the general population Celiac Disease Massage and Celiac Disease NO CONTRAINDICATIONS Depending on patients symptoms, massage around the abdomen may need to be adjusted or avoided Inflammatory Bowel Disease Inflammatory conditions of the bowel broken down into two diseases: Crohn’s Disease Ulcerative Colitis (UC) Crohn’s Disease Definition Immune mediated inflammatory disease characterized by transmural inflammation may involve any part of the GI tract, from oral cavity to perianal area Get characteristic “skip lesions” Crohn’s Disease Crohn’s Disease Etiology An idiopathic, autoimmune condition Immune mediated inflammatory disease characterized by transmural inflammation and damage to the lining of the GI tract Crohn’s Disease Pathophysiology Full thickness of bowel (transmural inflammation) is affected MC affected area: distal ileum & proximal colon 80% of patients have small bowel involvement (usually distal ileum) with 1/3 of patients having ileitis exclusively Skip lesions are common Crohn’s Disease Signs and Symptoms MC early sx is abdominal pain, diarrhea (with or without gross bleeding), fatigue, weight loss Abdominal pain usually cramping in quality (if dz limited to distal ileum, will be RLQ pain) Extraintestinal Sx: Enteropathic Arthritis (MC extraintestinal manifestation) Primarily involves large joints Can also be sacroiliitis or ankylosing spondylitis Uveitis, erythema nodosum, pyoderma gangrenosum, stomatitis Gallstones, renal stones Crohn’s Disease Complications Flare-ups Can be mild or severe, brief or prolonged Tend to reappear in same areas Can spread to adjacent area if diseased segment has been removed Obstruction d/t scarring Abscesses and/or fistula formation Increased risk of colon cancer with longstanding CD involving the colon (similar risk as UC) Crohn’s Disease Diagnosis GP suspects Crohn’s based on Hx of crampy abdominal pain and diarrhea and anal issues (bleeding, fissures, etc) PE may reveal palpable lump or fullness in RLQ Stool inflammatory markers Autoimmune markers on blood testing Confirmation: colonoscopy w/ biopsy and/or barium x-ray Colonoscopy will not be useful if Dz is limited to small intestine Crohn’s Disease Treatment No cure; Tx aimed at relieving SSx and reducing inflammation Antidiarrheal, anti-inflammatories, corticosteroids, dietary changes SSx may resolve w/o any Tx Some require surgical removal of small intestine or colon, to repair fistula, or to remove obstruction Not curative, can recur in any location of GI tract Crohn’s Disease Massage and Crohn’s Disease LOCAL CONTRAINDICATION During flare-ups, no massage over the area Discuss with patient their level of comfort with abdominal massage Ulcerative Colitis Definition Chronic, autoimmune disease characterized by recurring episodes of inflammation limited to the mucosal layer of the colon Affected area: rectum and sigmoid colon Limited to the large intestine Progressive lesions (continuous lesions) Ulcerative Colitis Etiology idiopathic autoimmune Genetic connection, dietary and infections can exacerbate or trigger Epidemiology SSx usually begin between 15 and 30 small number of persons with UC don’t have first attack until ages 50-70 Ulcerative Colitis Symptoms Diarrhea (more often associated with blood than in Crohn’s), bowel urgency, possible bowel incontinence, LLQ abdominal pain If dz is limited to the rectum, stool will be dry but will have mucus, WBC, and RBC If dz extends through the colon, stool is looser and BM are more frequent Extraintestinal Enteropathic Arthritis – typically involving large peripheral joints, also includes ankylosing spondylitis Uveitis, erythema nodosum, pyoderma gangrenosum Ulcerative Colitis Complications Severe bleeding – may occur in up to 10% of patients with UC and may necessitate urgent colectomy (MC complication) Resulting in Iron deficiency anemia Toxic megacolon – massive distention of colon sx of > 10 stools/day, continuous bleeding, abdominal pain and distention, fever anorexia Characterized by colonic diameter >6cm and presence of systemic toxicity Perforation – most commonly occurs as a consequence of toxic megacolon Increased risk of colon cancer Higher risk when entire colon is affected Higher risk if dx is >8 years, even if dz is not clinically active Flareups – often gradual onset w/ defecation urgency, mild cramps, and stools w/ blood and mucus Some have sudden and severe flare-up of sx w/ profound illness Can last weeks to months and can recur at any time Ulcerative Colitis Diagnosis History, symptoms, and a stool sample are initial indicators Confirmation: sigmoidoscopy and/or barium studies Colonoscopy later used to determine extent of damage Prognosis Chronic w/ repeated flare-ups and remissions Rapidly progressive initial attack w/ serious complications in 10% Treatment Tx aimed at controlling inflammation, reducing sx, and replacing lost fluids and nutrients Antidiarrheal and anti-inflammatory drugs, corticosteroids Dietary changes: iron supplements, avoiding raw fruits/vegetables Surgery: colectomy is curative Ulcerative Colitis Massage and Ulcerative Colitis LOCAL CONTRAINDICATION During flare-ups, no massage over the area Discuss with patient their level of comfort with abdominal massage Inflammatory Bowel Disease Inflammatory Bowel Disease Malabsorption Syndrome Definition Absorption through the small and/or large intestine is compromised Many causes, but usually due to damage to the mucous membrane of the GI tract Malabsorption Syndrome Signs and Symptoms SSx depend on the nutrients that are not absorbed MC general SSx: weight loss Fats: light-colored, soft, foul smelling stools (steatorrhea) Float, stick to side of bowl, and are difficult to flush away CHO: explosive diarrhea, bloating, and flatulence Protein: generalized swelling, dry skin, hair loss Calcium: bone pain and deformities w/ increased risk of Fx and osteoporosis, muscle spasms, tooth decay and discoloration Iron: microcytic anemia w/ fatigue and weakness Malabsorption Syndrome Signs and Symptoms Magnesium: muscle cramps Vitamin A: night blindness and dry eyes Thiamine B1: wet or dry Beriberi syndrome with neurological changes and cardiovascular effects Riboflavin B2: glossitis, angular cheilitis Niacin B3: pellagra (4 Ds – dermatitis, diarrhea, dementia, death), beefy glossitis Folate B9: megaloblastic anemia w/ fatigue and weakness Cobalamins B12: megaloblastic anemia, peripheral glove and stocking neuropathies Vitamin C: scurvy w/ connective tissue weakness Vitamin D: osteomalacia Vitamin K: bleeding Malabsorption Syndrome Diagnosis Based on SSx and weight loss despite a healthy diet Various blood tests can help confirm and Dx specific malabsorbed nutrients Fat is malabsorbed in most malabsorption disorders Stool samples to monitor for >7g of fat in stool/day Potential biopsy to dx underlying cause Treatment Depends on cause Malabsorption Syndrome Massage and Malabsorption Syndrome NO CONTRAINDICATIONS Depending on patients symptoms, massage around the abdomen may need to be adjusted or avoided