Digestive Path Lecture 2 PDF

Diseases of the Gastrointestinal System Part 2 Lecture Outline: Disorders of the Intestines Dr. Kevin Tipper, ND Irritable Bowel Syndrome (IBS) Definition...

Diseases of the Gastrointestinal System Part 2 Lecture Outline: Disorders of the Intestines Dr. Kevin Tipper, ND Irritable Bowel Syndrome (IBS) Definition Disorder of the intestine characterized by abnormal bowel motility Unlike inflammatory bowel disease (IBD), there is no damage to the intestinal lining or increased risk of colon cancer It is a “functional” disorder impairment of body’s normal function i.e. peristalsis, sensitivity of enteric nerves, and/or CNS digestive pathways No structural involvement Irritable Bowel Syndrome (IBS) Epidemiology Affects ~15% of population and women are slightly more at risk Usually begins in mid – 20s, most cases start prior to 35 yo Peoplewith anxiety and/or depression are more likely to be affected by IBS Suggestive of the link between the gut and the brain (gut-brain axis) Irritable Bowel Syndrome (IBS) Etiology Generally unknown mechanism Visceral hypersensitivity to various stimuli (certain foods and emotional stress) Risk factors: previous gastroenteritis or food poisoning, stress, anxiety, and depression Triggers: variable, but may include diet, eating too quickly or irregularly, drugs, hormones Triggers are inconsistent Irritable Bowel Syndrome (IBS) Signs and Symptoms Colicky, lower abdominal pain that is relieved with defecation Change in frequency and consistency of bowel movements Constipation (IBS-C) Diarrhea (IBS-D) Or both (IBS-M, mixed) Bloating and distension of abdomen Sensation of incomplete emptying after bowel movements Mucus in stool Systemic SSx: nausea, H/A, fatigue,anxiety, depression, and difficulty concentrating Irritable Bowel Syndrome (IBS) The Bristol Stool Chart a medical aid designed to classify stools 1 & 2 indicate constipation 3 & 4 are considered normal 5 may or may not be normal 6 & 7 indicate diarrhea Irritable Bowel Syndrome (IBS) Diagnosis Symptom-based diagnosis PE is usually WNL, except for potential tenderness w/ colon palpation Blood tests, stool samples, and colonoscopy are used to r/o more serious conditions (IBD, ulcers, or cancer) Indications for Referral: Consistent rectal bleeding Weight loss Unexplained IDA (iron-deficiency anemia) FMHx (family medical history) colorectal CA 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 Increase physical activity Stress, anxiety, and depression management including anxiolytic and antidepressant medications Research on probiotics for treatment of IBS is mixed Irritable Bowel Syndrome (IBS) Common triggers include fatty foods, fried foods, highly processed foods and some of the foods in the chart to the right Dairyand gluten may be fine for many people not suffering from lactose intolerance or gluten allergy/sensitivity FODMAPS are fermentable IBD vs. IBS Irritable Bowel Syndrome (IBS) Massage and Irritable Bowel Syndrome (IBS) possible LOCAL CONTRAINDICATION Avoid the abdomen during massage if it causes the patient discomfort Diverticulosis Definition Diverticula: balloon-like pouch that can form along the wall of any hollow structure in the body True diverticula: all four layers of intestinal wall (mucosa to serosa) Pseudodiverticula: mucosa and submucosa poke through and past muscle layer and are covered only by serosa (more common) MC affected area is the sigmoid colon Diverticulosis Definition Affects areas where vessels traverse muscle layer (ie. where the vasa recta penetrate the circular muscle layer of the colon) Diverticulosis Epidemiology Prevalence is age dependent, increased risk with increased age Less than 10% younger than 40 20% at age 40 60% at age 60 Mostpatients with are older than 50 years; the mean age at presentation appears to be about 60 years Diverticulosis Etiology High pressure in the lumen Potentially related to low fiber diet and constipation Theories: smooth muscle contractions are exaggerated and/or abnormal in certain areas, causing higher pressure Mechanism for abnormal contractions/spasms is unclear Genetic CT disorders (i.e. Marfan and Ehlers Danlos syndromes) Signs and Symptoms Usually asymptomatic unless complications occur Often an incidental finding on colonoscopy Vague abdominal pain, BM irregularity Diverticulosis Complications If the diverticula worsens or gets infected it can cause various complications such as: 1. Diverticulitis (1-4% of patients) 2. Diverticular bleeding (5-15% of patients) 3. Fistula Diverticulosis Complications Diverticulitis (1-4% of pt) Inflammation of infection of diverticula, often due to impacted fecal matter and associated colonic bacteria May result in perforation and peritonitis SSx: LLQ pain, constant, fever, perhaps palpable mass in LLQ d/t inflammation, abdominal guarding, rigidity and tenderness note that hematochezia is RARE with an acute diverticulitis flare Diverticulosis Complications Diverticular bleeding (5-15% of pt) As a diverticulum herniates, the penetrating vessel responsible for the wall weakness at that point becomes draped over the dome of the diverticulum, and is susceptible to bleeding Diverticular bleeding TYPICALLY occurs in the absence of diverticulitis Diverticulosis Diagnosis GP suspects based on SSx and is confirmed by colonoscopy or barium x-ray Colonoscopy is used when bleeding is present – best to determine source CT performed if severe pain is present Treatment Reduction of pressure and spasms High fiber diet and increasing fluid intake Uncomplicated bleeding is self-limiting and does not require Tx If bleeding continues, curettage is performed during colonoscopy Recurrent bleeding may require colectomy Diverticulitis is Tx w/ antibiotics to limit bacterial overgrowth Diverticulosis Massage and Diverticulosis possible LOCAL CONTRAINDICATION Avoid the abdomen during massage if it causes the patient discomfort Forpatients with diverticulitis, avoid massage until the condition has been treated Hemorrhoids Definition Swollen blood vessels located in the anal canal (internal hemorrhoids) or around the anus (external hemorrhoids) Very common condition Nearly 3 out of 4 adults will have hemorrhoids in their Hemorrhoids Etiology Prolonged pressure on the anus, including: Prolonged sitting Pregnancy and childbirth Obesity Constipation and/or diarrhea and accompanying straining (i.e. IBS) Low-fiber diet Advanced age Hemorrhoids Signs and Symptoms Internal hemorrhoids often cause rectal bleeding, but minimal pain Bright red blood Externalhemorrhoids can fill with blood, enlarge, and cause discomfort If irritated, external hemorrhoids may itch or bleed Diagnosis Diagnosed via digital rectal exam (DRE) or visual inspection Hemorrhoids Treatment Conservative treatment is often curative and includes: Eat high-fiber foods Use topical treatments Topical witch hazel, corticosteroids, phenylephrine, or lidocaine Preparation H are various combinations of the above ingredients Phenylephrine is a sympathomimetic that vasoconstricts blood vessels Soak regularly in a warm bath or sitz bath Analgesics by mouth If these treatments do not bring improvement or relief, surgical removal may be necessary Hemorrhoids Massage and Hemorrhoids No contraindications Be cautious of patient positioning and comfort Appendicitis Definition Inflammation of the vermiform appendix MC surgical emergency of abdomen (affects 10% of population) Incidence is highest in the 10-19 yo age group Etiology Obstruction is the primary cause Fecolith Fibrosis Parasite infection Children: lymphoid hyperplasia d/t infection Appendicitis Signs and Symptoms First SSx: periumbilical pain w/ nausea, vomiting, and anorexia Nausea passes and pain shifts to RLQ Positive McBurney’s sign, Rovsing’s sign, psoas sign, obturator sign Positive rebound tenderness Abdominal guarding Low grade fever Children have more vague pain pattern Pregnant women and elderly have milder tenderness Appendicitis Physical Examination McBurney’s sign Rovsing’s sign Psoas sign Obturator sign Positive rebound tenderness Abdominal guarding Appendicitis Complications Rupture/Perforation increase risk of rupture/perforation w increasing age and if male Can lead to abscess formation, intra abdominal infection, sepsis Initial relief of pain, followed by high fever and peritonitis Inflammation and scarring of fallopian tube can cause infertility Appendicitis Diagnosis Suspected on Hx and PE Increased WBC on CBC/blood tests CT or US may be performed Exploratory laparoscopic surgery performed to confirm Appendix often removed even if it is not inflamed Treatment For most (regardless if perforated or not), appendectomy followed by IV antibiotics Appendicitis Massage and Appendicitis ABSOLUTE CONTRAINDICATION Patient needs emergent medical treatment Peritonitis Definition Inflammation of the inner membrane that lines the abdominal cavity and abdominal organs Most commonly caused by secondary infection Peritonitis Types (Classified based on etiology) Spontaneous Bacterial Peritonitis (SBP; aka primary): the development of ascitic fluid infection without an evident intra-abdominal infection Most often a complication of advanced cirrhosis Secondary Peritonitis: Much more common than SBP Infectious disease of intra-abdominal organs spreads to the peritoneum Most 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, N/V, chills Sudden, severe abdominal pain worse with movement Abdominal tenderness Complications Dehydration, electrolyte imbalances, sepsis Treatment Surgery to remove infected issue or drain fluid IV Antibiotics, and pain medications Peritonitis Massage and Peritonitis ABSOLUTE CONTRAINDICATION Peritonitis is a medical emergency and requires immediate medical attention Viral Gastroenteritis Definition Viral infection of intestine that cause nausea, vomiting, and watery diarrhea “stomach flu” Etiology Rotavirus: most common cause of diarrhea in children under 2 years old Spread fecal-oral route Immunity develops and each subsequent infection is less intense Rare in adults Norwalk virus: occurs in small epidemics and usually heal without consequence Spread fecal-oral route or person-to-person contact, and/or air droplets of vomited virus Bacterial Gastroenteritis Definition Loose stools caused by various bacterial infections Bacteria invade and colonize intestine, then cause inflammation and destroy tissue Etiology Bacterial toxins: pre-formed in food then ingested or released by bacteria growing outside the intestine S. aureus or e. coli: food poisoning caused by unrefrigerated/contaminated food Clostridium botulinum: botulism caused by canned food Lytic bacteria: enterotoxigenic bacteria enter colon and destroy tissue E. coli: traveler’s diarrhea (enterocolitis) caused by contaminated food or water Invasive bacteria: produce intestinal inflammation, ulcerations, bleeding, and/or perforation Shigella and salmonella Can enter blood and lymphatics to cause systemic infection Protozoal Enteritis Definition Parasitic infection of the intestine Common in those traveling to southern countries Etiology Giardia lambia (“Beaver Fever”): infection of small intestine caused by contaminated water Causes diarrhea and/or malabsorption Entamoeba histolytica: anaerobic ameba common in tropical locations Infects travelers more than local residents Usually asymptomatic carriers; pass parasite unknowingly 10% of people have tissue destruction from parasitic metabolism resulting in ulceration Infectious Diseases Massage and Infectious Diseases CONTRAINDICATION Patientsshould not be in your office if they are feeling unwell Intestinal Ischemia Definition A group of disorders that result from compromised blood flow in segments of the intestine (can affect LI or SI) Etiology any process that reduces intestinal blood flow atherosclerosis emboli/thrombi of various intestinal arteries arterial vasospasm Acute: sudden onset and associated w/ high mortality Chronic: mild, non-specific SSx that often goes undiagnosed Intestinal Ischemia Ischemic Colitis Definition blood flow to part of the colon is slowed or blocked Etiology Hypotension (shock or severe dehydration) Atherosclerosis or thrombosis Volvulus or incarceration Intestinal Ischemia Acute Mesenteric Ischemia Definition Sudden onset of small intestinal hypoperfusion Etiology Arterial embolism brought on by CHF, arrhythmia or an MI MC cause of acute mesenteric ischemia Atherosclerosis or thrombosis Decreased blood flow from low cardiac output, CHF, or kidney failure Intestinal Ischemia Signs and Symptoms Sudden, severe abdominal pain out of proportion of physical examination N/V Peritonitis w/ rebound tenderness Increasing tenderness over the course of ischemia Lack of blood flow > 10 hours causes intestinal necrosis Bacteria can invade the system and cause organ failure, shock, and death Diagnosis Depends on a high level of clinical suspicion, especially in those patients with RFs for peripheral embolization (afib, recent MI, valvular Dz, atherosclerosis, etc.) Angiography Intestinal Ischemia Treatment TPA hemolytic agents during angiography Immediate surgery is required Stents, bypass, or removal of obstructive vessels Post-op anticoagulants to prevent future clots Prognosis Early diagnosis often allows full recovery Advanced intestinal ischemia requires bowel resection, which is associated with a 15x increase in mortality Late diagnosis w/ bowel necrosis results in death for 70-90% Intestinal Ischemia Massage and Intestinal Ischemia ABSOLUTE CONTRAINDICATION Intestinal ischemia is a medical emergency and requires immediate medical attention Intestinal Atresia Definition Congenital, complete obstruction of intestinal lumen Presentation abdominal distention and bilious emesis in first 2 days of life Treatment Surgical resection with anastomosis of uninvolved segments Intestinal Atresia Massage and Intestinal Atresia N/A Will be treated in first few days of life Meckel’s Diverticulum Definition Congenital outpouching of the intestine due to a remnant of embryonic connection between the intestine and umbilicus Usually an appendage of the ileum Most common malformation of GI tract Often asymptomatic and undiagnosed Can become filled with food or fecolith and become infected or rupture Meckel’s Diverticulum Symptoms Usually asymptomatic Rectal bleeding, epigastric and LLQ pain, nausea Complications Intestinal obstruction, volvulus, and/or intussusception Treatment Surgical removal Meckel’s Diverticulum Meckel’s Diverticulum Massage and Meckel’s Diverticulum LOCAL CONTRINDICATION Hirschsprung’s Disease Definition Congenital disorder that occurs when part of the intestine lacks innervation Missing nerve networks result in dysfunction and lack of peristalsis Signs and Symptoms failure to pass meconium within first 48 hours of life, bilious vomiting, and abdominal distension Small percentage diagnosed later in life: anorexia, distension, bilious vomiting, constipation Hirschsprung’s Disease Complications Megacolon, intestinal obstruction, perforation volvulus, and/or intussusception Treatment Temporary colostomy May need long term high fiber diet and/or laxatives Hirschsprung’s Disease Hirschsprung’s Disease Massage and Hirschsprung’s Disease LOCAL CONTRAINDICATION Intussusception Definition aka telescoping An intestinal disorder in which a segment of the intestine folds in on itself Serious complications include: Intestinal obstruction Vascular blockage and tissue infarction Most commonly occurs in the ileocecal region Intussusception Intussusception Epidemiology most common cause of intestinal obstruction in children younger than 3 years old rare in adults most cases of adult intussusception are the result of an underlying medical condition, such as a tumor Intussusception Etiology Children (more common): most cases are idiopathic Risk factors: Meckel’s diverticulum, Hirschsprung’s Disease, intestinal malrotation, family history Adults: abnormal growth, such as polyp or tumor Acts as “leading edge” to pull bowel into itself Signs and Symptoms Intermittent abdominal pain, vomiting in an otherwise healthy child, palpable mass in abdomen Children may guard abdomen: knees to chest position Intussusception Complications Intestinal obstruction on volvulus Ischemia and infraction Causes sloughing of tissue Results in intestinal mucosa, blood, and mucus in stool: red, jelly-like stool Perforation and peritonitis Intussusception Diagnosis Abdominal US or CT shows “bulls eye” Treatment Fluid or air enema to unfold intestine Is usually enough to fix intussusception in children (90%) Surgery to clear obstruction, remove infarcted tissue, or repair perforation Usually required in adults Intussusception Massage and Intussusception ABSOLUTE CONTRAINDICATION Intussusception is a medical emergency and requires immediate medical attention Volvulus Definition Twisting of a loop of intestine around itself and its surrounding mesentery Serious complications include: Intestinal obstruction Vascular blockage and tissue infarction Can lead to perforation and peritonitis MC affected area is the sigmoid colon Also affects the cecum and midgut Volvulus Etiology Pregnancy fetus causes displacement and twisting of colon Constipation stool acts as pivot point for intestine to twist around Abdominal adhesions from injury, surgery, or infection scar tissue creates a physical attachment that can act as a pivot point for the intestine to twist around Hirschsprung's Disease Volvulus Signs and Symptoms severe abdominal pain Abdominal distention constipation, bloody stool, vomiting Diagnosis X-ray (w/ or w/o barium) Treatment Sigmoidoscopy Tubes able to relieve pressure and untwist colon Surgical resection if infarction occurs Volvulus Massage and Volvulus ABSOLUTE CONTRAINDICATION Volvulusis a medical emergency and requires immediate medical attention Strangulation Definition Trapping and cutting off of blood supply to intestinal tissue Etiology Herniation, intestinal obstruction, volvulus, intussusception Signs and Symptoms Steady, severe pain with fever Complications Gangrene: tissue damage with significant putrefaction Can develop in as few as 6 hours Often causes rupture that leads to peritonitis, shock, and – if untreated – death Strangulation Hernia Adhesion Intussusception Volvulus Strangulation Massage and Strangulation ABSOLUTE CONTRAINDICATION Strangulation is a medical emergency and requires immediate medical attention Familial Adenomatous Polyposis Definition Autosomal dominant disease causing numerous colonic polyps, resulting in carcinoma by age 40 if left untreated 50% have polyps by age 15; 95% by age 35 Normal numbers are 15-40% of adults Signs and Symptoms Often asymptomatic Rectal and/or occult bleeding Familial Adenomatous Polyposis Diagnosis Stool sample positive for occult blood Presence of >100 polyps on colonoscopy Genetic testing to identify mutation First degree relatives should also be tested Treatment Colectomy at time of diagnosis May or may not leave rectal remnant If left, requires biyearly screening Familial Adenomatous Polyposis Massage and Familial Adenomatous Polyposis No contraindication Colorectal Carcinoma Definition adenocarcinomas that develop in glandular intestinal lining of the colon or rectum Usually begins as benign polyp Due do large lymph supply and vascular relationship to liver, early Colorectal Carcinoma Epidemiology Third most common cancer worldwide Second leading cause of cancer deaths in Western countries More common in males assigned at birth 1/16 males and 1/18 females will develop colorectal cancer Womenare more prone to colon CA and men are more prone to rectal Colorectal Carcinoma Risk Factors Family history of colorectal cancer and FAP Ulcerative colitis and, to a lesser degree, Crohn’s disease High fat, low fiber diet Smoking and alcohol Signs and Symptoms Generally slow growing w/o SSx in early disease First sign is usually blood in stool A change in bowel habits, such as more frequent diarrhea or constipation Possible bowel obstruction Ongoing discomfort in the belly area, such as cramps, gas or pain Colorectal Carcinoma Diagnosis Screening (colonoscopy and/or FIT) should be performed in all persons over 50 Fecal Immunochemical Test (FIT) Tests for occult blood in stool Every two years for average risk Colonoscopy 40 for persons with significant family Hx Any polyps are removed during procedure and sent to pathology Stool sample for occult blood Positive tests requires colonoscopy Abdominal CT and CXR are required to identify any metastatic disease Colorectal Carcinoma Treatment Surgical resection of colon and local lymph is primary treatment Curative in 90% of cases when CA is only lining the bowel wall, 70% of cases when CA extends through the bowel wall Drops to 30% with metastatic disease May require pre-surgical chemo to shrink tumor Temporary or permeant colostomy Colorectal Carcinoma Staging Colon Cancer STAGE 0: limited to lining of intestine that covers a polyp. >95% five year survival rate STAGE 1: spread through space between mucosa and muscle layer. This space contains vessels, nerves, and lymph. 90% five year survival rate STAGE 2: invasion of muscle layer and serosa. 55-85% five year survival rate STAGE 3: extension through serosa and into nearby lymph nodes. 20- 55% five year survival rate STAGE 4: metastatic spread to other organs, such as liver, lungs, ovaries, or peritoneum.