Notes – GI System PDF

Notes – GI System 2025-01-27 6:45 PM Diseases of the GI System: Part 1 Disorders of the Esophagus Disorders of the stomach...

Notes – GI System 2025-01-27 6:45 PM Diseases of the GI System: Part 1 Disorders of the Esophagus Disorders of the stomach IBD (Crohn's/UC) Celiac Disease Malabsorption Syndrome Disorders of the Esophagus: Hiatal Hernia GERD Hiatal Hernia: 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 Quite common – just have few symptoms Presentation Minor to severe reflux Indigestion, bloating, and/or dysphagia (difficulty swallowing) Etiology Unknown cause for most hiatal hernias, however there are certain things that increase risk: Age – related changes in your diaphram ( >50, progressive weakness) Injury to the area – 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, exercising or lifting heavy objects Obesity Types: Two types – categorized by what portion of the stomach bulges through the diaphragm 1. Sliding Hernia (Type I) 95% Protrusion of the LES and gastroesophageal junction through the diaphragm Creates bell-shaped dilation d/t construction of LES about and constriction of diaphragmatic narrowing below 2. Paraesophageal Hernia (Type II) 5% Much less common – but much worse/severe Fixed protrusion of a separate portion of the stomach into the thorax – paraesophageal LES and gastroesophageal junction remain below the diaphragm, while herniated portion is beside the esophagus Signs & Symptoms Most sliding hernias are asymptomatic or have minor SSx - most likely heartburn or indigestion M/C 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 Complications Strangulation Painful and emergent complication of paraesophageal hernias Stomach pinched by diaphragm loses blood supply Symptoms: chest pain, bloating, belching and dysphagia Perforation of GI is extremely bad – bacteria can spread to peritoneum and cause bacteria in all GI 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 Prescriptions: H2 blockers or PPI (proton pump inhibitors) Paraesophageal hernias that cause symptoms should be surgically repaired to prevent strangulation Massage LOCAL CONTRAINDICATION Avoid or only light pressure over affected area Be conscious of patient positioning and comfort Gastroesophageal Reflux Disease (GERD): 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 Heartburn vs. GERD Heartburn is a symptom GERD is a chronic disease where people suffer from heartburn too often - chronic consistent heartburn Etiology Malfunction of LES (Lower Esophageal Sphincter) permits stomach contents into esophagus Risk factors: Hiatal hernia Obesity Pregnancy Fatty foods Chocolate Caffeinated and carbonated drinks Alcohol, smoking and certain drugs Spicy foods Anticholinergic drugs, calcium channel blockers, progesterone, and nitrates may interfere with LES function Signs and Symptoms M/c symptom – heartburn and regurgitation Occasionally pain extends to neck, throat and face – referral pattern Other symptoms Sore throat, hoarseness, excessive salivation, sensation of lump in throat, dry cough Slight or massive bleeding d/t inflammation Vomited (red) or passed as black, tarry stool (melena) Complications 1. Esophageal ulcers d/t chronic reflux (present like heartburn) 2. Stricture d/t chronic ulceration Dysphagia, SOB, and wheezing 3. Barret's Esophagus – metaplastic changes d/t acid irritation Precancerous Changes may occur even in the absence of symptoms Switch of cell type from stratified squamous epithelium to columnar Diagnosis Based on symptoms; no diagnostic tests needed to start treatment Special testing available when diagnosis is unclear or when treatment has failed to control symptoms Endoscope (camera down the throat) * Esophageal pH testing * x-ray studies pressure measurement of LES Treatment Lifestyle changes: similar to changes for hernias * Eating habits, remove irritating foods Parasympathetic stimulators to tightly close LES H2 (histamine-2 receptor) blockers or PPIs (proton pump inhibitors) to reduce acid Massage No contraindications Be mindful of patient positioning and timing of massage Disorders of the Stomach: Diaphragmatic hernia Pyloric stenosis Gastritis Peptic ulceration Gastric cancer Diaphragmatic Hernia: Protrusion of 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 Etiology Congenital Due to embryologic defect of diaphragm affected neonates usually present in the first few hours of life w/ respiratory distress Acquired Most common cause is blunt force trauma diaphragm usually injured in association w/ other thoracic and abdominal organs Signs & Symptoms Abdominal pain Decreased breath sounds SOB Auscultation of bowel sounds in chest Potential bulge Nearly ½ of adults don’t have any signs or symptoms 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 possible, but rare Routine check-ups w/ CXR and PFTs Massage LOCAL CONTRAINDICATION Avoid or only light pressure over effective areas Be conscious of patient positioning and comfort Pyloric Stenosis: Congenital or acquired pyloric hypertrophy resulting in blockage of passageway between stomach and duodenum Pylorus function: Contracts to keep food in stomach for digestion Relaxes to release food into duodenum Results in gastric outlet obstruction – prevents stomach from emptying into SI and food backs up into esophagus Etiology 1. Congenital More common – congenital, idiopathic hypertrophy that becomes apparent w/in the first month of life Possible genetic component Linked to other genetic and congenital conditions 3-4x more common in males 2. Acquired Pyloric hypertrophy related to gastritis or peptic ulcer near gastric antrum Signs & Symptoms Regurgitation Persistent, projectile, nonbilious vomiting after feeding – projectile vomiting Can lead to dehydration and failure to thrive in infants – baby doesn’t grow 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 ultrasound Treatment Surgical muscle splitting – pyloromyotomy IV fluids – to correct dehydration Massage LOCAL CONTRAINDICATION Acute Gastritis: 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 Etiology Most common causes – NSAIDs (asprin), H. pylori EtOH, smoking, and crohn's Emotional stress Increased acid production and decreased mucous production Emotional stress is arguable in a lot of cases – very debatable Severe stress to the body Illness or injury w/ severe burns or bleeding Results in ischemia of mucosal lining People who take chronic NSAIDS Decreased prostaglandins ---> decrease mucous lining in the stomach H.pylori - big concern for people with stomach issues Prefers to live in the stomach – thrive in the stomach acids Linked to a lot of stomach diseases Signs & Symptoms Often there are no symptoms, but are variable if they do occur Common symptoms – epigastric pain/pressure, indigestion, nausea/vomiting Severe symptoms – overt hemorrhage, massive hematemesis (vomit blood), melena (blood in stool) Anemia w/ fatigue, weakness, and light-headedness Complications 1. Ulceration w/ significant bleeding 2. Gastric perforation w/ peritonitis 3. Gastric atrophy leading to chronic gastritis Massage LOCAL CI Avoid abdominal massage Patient w/ acute gastritis may need medical treatment depending on severity Postpone massage until recovered Chronic Gastritis: Inflammation of the gastric mucosa w/ 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 Etiology Subtypes – autoimmune & environmental H.pylori is most common environmental cause Other examples – NSAIDs (asprin), EtOH, smoking, crohn's Signs & Symptoms Most 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 d/t lack of B12 absorption Sublingual supplement to help w/ this Treatment Discontinue and avoid drugs that can aggravate gastritis – aspirin, NSAIDs Eradicate H. pylori Triple therapy PPIs – decrease stomach acid Two antibiotics Massage LOCAL CI Avoid abdominal massage Patient w/ 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 – usually shallow gastric lesions w/o mounted immune response and are related to NSAIDs Anatomic Classifications 1. Duodenal Most common type Occurs in first few inches of unprotected duodenum d/t gastric juice and digestive enzymes 2. Gastric Typically occur along lesser curvature at the antrum stomach 3. Marginal Occur where stomach has been surgically removed and anastomosed to intestine Etiology Imbalance in gastroduodenal mucosal defence mechanisms and damaging forces – HCI and pepsin Most common 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 Signs & Symptoms 70% of peptic ulcers are asymptomatic Most common symptom – gnawing, burning, aching epigastric pain Pain often waxes and wanes – in periods of weeks or months Other symptoms – hematemesis, bloating, belching Complications include – iron-deficiency anemia, hemorrhage, or perforation (usually in children and elderly) Gastric Ulcer Symptoms Gastric antrum or near pylorus Epigastric pain AFTER eating Pain worse with eating (weight loss) Early satiety Can lead to gastric carcinoma Duodenal Ulcer Symptoms First few inches of duodenum Epigastric pain with EMPTYING stomach Increased night pain d/t increase acidic output at night Decreased pain shortly after eating (weight gain) Pain occurs 2 – 5 hours post meal Cannot lead to gastric carcinoma Complications Fistula Burrowing through muscular wall of stomach or duodenum and continuing into an adjacent organ – fistula Perforation Occurs in 2 – 10% of PUD patients 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 grounds) of partially digested blood 10% mortality rate Melena or hematochezia Excessive scarring Cicatrization Healing of ulcerated tissue Leads to gastric outlet obstruction Gastric outlet obstruction Inflamed tissue around ulcer swells or scars and narrows pyloric antrum Can occur w/ 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 Diagnosis Suspicion related to characteristic abdominal pain Test may be needed to confirm – endoscopy or barium x-ray Used when treatment fails to resolve symptoms Used when pt is > 45 years old and has symptoms of weight loss (rule out gastric cancer) Barium w/ a perforation = peritonitis Barium is really irritating to the peritoneum Endoscopy – safer Treatment Discontinue any NSAIDs use or any other irritants Antibiotics for H. pylori infection Neutralize or reduce stomach acid w/ OTC or drugs while ulcer heals Do not themselves heal ulcers, but relieve symptoms and raise pH of stomach Take for 4-8 weeks Massage LOCAL CONTRAINDICATION If the patient has abdominal discomfort, it is best to avoid abdominal massage Gastric Cancer: Primary adenocarcinomas from glandular cells of the stomach 95% of gastric cancers are primary adenocarcinomas Epidemiology Most common population – > 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 Etiology Risk factors: H.pylori infection Large or multiple gastric polyps Potential dietary link – smoked, salted, pickled food, nitrates Smoking and obesity Major risk factor for gastric cancer is H. pylori infection w/ sustained inflammation of gastric lining Signs & Symptoms Early signs and symptoms 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 symptoms Signs and Symptoms include: Weight loss (M/C) - results from insufficient caloric intake d/t nausea, pain, early satiety Abdo pain – when present, epigastric and mild Nausea – usually a result of the tumour mass itself that disrupts ability of stomach to distend Dysphagia – more common with CA arising at gastroesophageal junction Melena, early satiety, ulcer type pain m/c PE finding of metastatic diagnosis is enlarged L supraclavicular lymph node – Virchow's node 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 5 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 Massage No CI'S Be aware of patients comfort in certain positions Disorders of the Intestines: Celiac disease Inflammatory bowel disease – IBD, Crohn's and UC Malabsorption Syndrome Celiac Disease: Aka celiac spruce, 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 Etiology Risk Factors Having a 1st or 2nd degree relatives with celiac – genetic component Often associated with other autoimmune diseases Type 1 Diabetes Autoimmune thyroiditis Down's Syndrome and Turner Syndrome Signs & Symptoms Symptoms depend on severity of damage to small intestine GI symptoms Chronic diarrhea (foul smelling stools), bloating, malnutrition, weight loss Malabsorption syndromes and resultant symptoms Extraintestinal symptoms Dermatitis Herpetiformis – multiple pruritic papules and vesicles in grouped arrangements m/c sites are elbows, dorsal forearms, knees, scalp, back, and buttock Diagnosis Symptoms raise suspicion and are followed up with blood or stool Ab-Ag tests Diagnosis confirmed w/ biopsy Treatment Gluten free diet Corticosteroids Prognosis Potential risk for developing lymphoma and GI cancer Unknown if GF diet decreases risk Small absolute increase in overall mortality in patients with celiac disease compared with the general population Massage NO CI's 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: 1. Crohn's Disease 2. Ulcerative Colitis 1. Chron's Disease: Immune mediated inflammatory disease characterized by transmural inflammation May involve any part of the GI tract, from oral cavity to perianal areas Get characteristic "skip lesions" Etiology An idiopathic, autoimmune condition Immune mediated inflammatory disease characterized by transmural inflammation and damage to the lining of the GI tract Pathophysiology Full thickness of bowel (transmural inflammation) is affected Most common affected areas – 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 Signs & Symptoms GI Symptoms Most common early symptoms – abdominal pain, diarrhea (w/ or w/out gross bleeding), fatigue, weight loss Abdominal pain usually cramping in quality – RLQ pain Extraintestinal Symptoms Enteropathic Arthritis – M/C extraintestinal manifestation Primarily involves large joints Can also be sacroiliitis or ankylosing spondylitis Uveitis – eye inflammation Erythema Nodosum – nodes in the skin Pyoderma gangrenosum – gangrene Stomatitis Gall stones, renal stones 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 due to scarring Abscesses and/or fistula formation Increased risk of colon cancer with longstanding CD involving the colon Disease: Crohn Disease Ulcerative Colitis Diagnosis Site of Origin Ileum or proximal colon Sigmoid colon or rectum GP suspects Chron's Based on Hx of crampy abdominal pain and diarrhea and anal issues (bleeding, fissures, ect) Can occur anywhere Only in large intestine Distal ileum most common PE may reveal palpable lump or fullness in RLQ Stool inflammatory markers Pattern of Progression "skip" lesions Proximally contiguous Autoimmune markers on blood testing Thickness of Inflammation Transmural Submucosa or mucosa Confirmation – colonoscopy w/ biopsy and/or barium x-ray Symptoms Crampy abdominal pain Bloody diarrhea - w/ mucous Colonoscopy will not be useful if disease is limited to small intestine Complications Fistulas, abscess, obstruction Hemorrhage, toxic megacolon Treatment No cure; treatment aimed at relieving symptoms and reducing inflammation Radiographic Findings String sign on barium x-ray Lead pipe colon on barium x-ray Antidiarrheal, anti-inflammatories, corticosteroids, dietary changes Symptoms may resolve w/o any treatment Risk of Colon Cancer Slight increase Marked increase Some require surgical removal of small intestine or colon, to repair fistula, or to remove obstruction Surgery For complications Curative Not curative, can recur in any location of GI tract Stricture Massage LOCAL CI During flare-ups, no massage over the area Discuss with patient their level of comfort with abdominal massage 2. Ulcerative Colitis: 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 Etiology Idiopathic autoimmune Genetic connection, dietary and infections can exacerbate or trigger Epidemiology Symptoms usually begin between 15 and 30 Small number of persons with UC don’t have first attack until ages 50 – 70 Symptoms GI Symptoms Diarrhea - more often associated with blood than in Chron's Bowel urgency, possible bowel incontinence, LLQ abdominal pain If disease is limited to the rectum, stool will be dry but will have mucus, WBC, and RBC If disease extends through the colon, stool is looser and BM are more frequent Extraintestinal Symptoms Enteropathic Arthritis Primarily involves large peripheral joints Can also include ankylosing spondylitis Uveitis – eye inflammation Erythema Nodosum – nodes in the skin Pyoderma gangrenosum – gangrene Complications Severe bleeding – may occur in up to 10% of patients with UC and may necessitate urgent colectomy m/c complication Resulting in iron deficiency anemia Toxic megacolon – massive distention of colon Symptoms of >10 stools/day, continuous bleeding, abdominal pain and distension, 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 diagnosis is >8 years, even if disease is not clinically active Flareups – often gradual onset w/ defecation urgency, mild cramps, and stools w/ blood and mucus Some have sudden and sever flare-up of symptoms w/ profound illness Can last weeks to months and can recur at any time 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 Treatment aimed at controlling inflammation, reducing symptoms, and replacing lost fluids and nutrients Antidiarrheal and anti-inflammatory drugs, corticosteroids Dietary changes – iron supplements, avoiding raw fruits/vegetables Surgery – colectomy is curative Massage LOCAL CI During flare-ups, no massage over the area Discuss with patient their level of comfort with abdominal massage Malabsorption Syndrome: 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 Signs & Symptoms Symptoms depend on the nutrients that are not absorbed Most common general symptom – weight loss Fats Light-coloured, soft, foul smelling stools Float, stick to side of bown, 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 fracture and osteoporosis, mm spasms, tooth decay and discoloration Iron Microcytic anemia w/ fatigue and weakness Diagnosis Based on symptoms and weight loss despite a healthy diet Various blood tests can help confirm and diagnose specific malabsorbed nutrients Fat is malabsorbed in most malabsorption disorders Stool samples to monitor for >7g of fat in stool/day Potential biopsy to diagnose underlying cause Treatment Depends on the cause Massage No CI's Depends on patients symptoms, massage around the abdomen may need to be adjusted or avoided Quiz 4: Diseases of the GI system (Disorders of the Intestines) Irritable Bowel Syndrome – IBS: 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 – no inflammation It is a "functional" disorder Impairment of body's normal function No structural involvement Epidemiology Affects ~15% of population and women are slightly more at risk Usually begins in mid – 20s, most cases start prior to 35 years old People with anxiety and/or depression are more likely to be affected by IBS Suggestive of the link b/w the gut and the brain – gut-brain axis 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, may include diet, eating too quickly or irregularly, drugs, hormones Triggers are inconsistent Signs & 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 distendsion of abdomen Sensation of incomplete emptying after bowl movement Mucus in stool Systemic symptoms: Nausea, H/A, fatigue, anxiety, depression, and difficulty concentrating 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 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 cancer 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 bowls Increase physical activity Stress, anxiety, and depression management including anxiolytic and antidepressant medication Research on probiotics for treatment of IBS is mixed Triggers Common triggers: Fatty foods Fried foods Highly processed foods 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 polysaccharides Massage Possible LOCAL CONTRAINDICATION Avoid the abdomen during massage if it causes the patient discomfort Diverticulosis: Diverticula – balloon-like pouch that can form along the wall of any hollow structure in the body True diverticula – all 4 layers of intestinal wall (mucosa to serosa) Pseudodiverticula – mucosa and submucosa poke through and past muscle layer and are covered only by serosa most common Herniated m/c affected areas is the sigmoid colon Affects areas where vessels traverse muscle layer (where the vasa recta penetrate the circular muscle layer of the colon) Epidemiology Prevalence is age dependent, increased risk with increased age Less that 10% younger than 40 20% at age 40 60% at age 60 Most patients with are older than 50 years; the mean age at presentation appears to be about 60 years Etiology High pressure in the lumen Potentially related to low fiber diet and constipation Makes the lumen squeeze even tighter because the poop is liquid 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 – Marfans and Ehlers Danlos syndromes Signs & Symptoms Usually asymptomatic unless complications occur Often an incidental finding on colonoscopy Vague abdominal pain, BM irregularity 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 Diverticulitis Inflammation of infection of diverticula, often due to impacted fecal and associated colonic bacteria May result in perforation and peritonitis Symptoms: 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 Diverticular Bleeding 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 No inflammation Diverticulitis is worse than diverticular bleeding Diagnosis DP suspects based on symptoms and is confirmed by colonoscopy or barium x-ray – m/c 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 Diverticulitis is Tx w/ antibiotics to limit bacterial growth Massage Possible LOCAL CONTRAINDICATION Avoid the abdomen during massage if it causes the patient discomfort For patients w/ diverticulitis, avoid massage until the condition has been treated Hemorrhoids: 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 lifetime (75%) Etiology Prolonged pressure on the anus, including Prolonged sitting Pregnancy and childbirth Obesity Constipation and/or diarrhea and accompanying straining (IBS) Low-fiber diet Advanced age Signs & Symptoms: Internal Hemorrhodis Often cause rectal bleeding, but minimal pain Bright red blood External Hemorrhoids Can fill with blood, enlarge, and cause discomfort If irritated, external hemorrhoids may itch or bleed Diagnosis Digital rectal exam (DRE) or visual inspection Treatment Conservative treatment is often curative and includes: Eat high-fiber foods Use topical treatments – Preparation H (witch hazel corticosteroids, phenylephrine – vasoconstrictor, or lidocaine) Soak regularly in a warm bath or sitz Analgesic by mouth If these treatments do not bring improvement or relief, surgical removal may be necessary Massage No contraindications Be cautious of patient positioning and comfort Appendicits: Inflammation of the vermiform appendix m/c surgical emergency of abdomen – affects 10% of population Incidence is highest in the 10 – 19 years old age group Etiology Obstruction is the primary cause: Fecolith - "poop rock" blocks the area and bacteria gets stuck m/c Fibrosis Parasite infection Children: lymphoid hyperplasia d/t infeciton Signs & Symptoms First symptoms – periumbilical pain w/ nausea, vomiting, and anorexia (lack of appetite) 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 Physical Examination McBurney's sign – pushing on that point Rovsing's sign Psoas sign Obturator sign Positive rebound tenderness – the rebound after you remove pressure from that point Abdominal guarding 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 Diagnosis Suspected on Hx and PE Increased WBC on CBC/blood test 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 Massage ABSOLUTE CONTRAINDICATION Pt needs emergent medical treatment Peritonitis: Inflammation of the inner membrane that lines the abdominal cavity and abdominal organs Most commonly caused by secondary infection Types: Classified based on etiology 1. Spontaneous Bacteria Peritonitis SBP; aka primary The development of ascitic fluid infection without an evident intra-abdominal infection Most often a complication of advanced cirrhosis 2. 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 Appendicitis, pancreatitis, peptic ulcer disease, perforated colon/diverticula Signs & Symptoms Fever, nausea/vomitting, chills Sudden, severe abdominal pain worse with movement Abdominal tenderness Complications 1. Dehydration 2. Electrolyte imbalance 3. Sepsis Treatment Surgery – to remove infected issue or drain fluid IV antibiotics, and pain medication Massage ABSOLUTE CONTRAINDICATION Medical emergency and required immediate medical attention Viral Gastroenteritis: Viral infection of intestine that cause nausea, vomiting, and watery diarrhea "stomach flu" aka food poisoning Etiology 1. 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 – b/c of vaccine and adults have a robust immune system 2. Norwalk virus Occurs in small epidemics and usually heal without consequence Spread: Fecal-oral route Person-to-person contact And/or air droplets of vomited virus Massage CONTRAINDICATION Patients should not be in your office if they are feeling unwell Bacterial Gastroenteritis: Loose stools caused by various bacterial infections Bacteria invade and colonize intestine, then cause inflammation and destroy tissue Etiology 1. 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 2. Lytic bacteria Enterotoxigenic bacteria enter colon and destroy tissue E.coli: travelers diarrhea (enterocolitis) caused by contaminated food or water 3. Invasive bacteria Produce intestinal inflammation, ulcerations, bleeding, and/or perforation Shigella and salmonella: can enter blood and lymphatics to cause systemic inflammation Massage CONTRAINDICATION Patients should not be in your office if they are feeling unwell Protozoal Gastroenteritis: Parasitic infection of the intestine Common in those traveling to southern countries Etiology 1. Giardia Lambia Aka. "Beaver Fever" Infection of small intestine caused by contaminated water Causes diarrhea and/or malabsorption 2. Entamoeba Histolytica Anaerobic amoeba 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 Massage CONTRAINDICATION Patients should not be in your office if they are feeling unwell Intestinal Ischemia: 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 symptoms that often goes undiagnosed Types: 1. Ischemic Colitis Blood flow to part of the colon is slowed or blocked Etiology Hypotension – shock or severe dehydration Atherosclerosis or thrombosis Volvulus or incarceration 2. Acute Mesenteric Ischemia Sudden onset of small intestinal hypoperfusion Etiology Arterial embolism brought on by congestive heart failure, arrhythmia or an MI - m/c cause of acute mesenteric ischemia Atherosclerosis or thrombosis Decreased blood flow from low cardiac output, CHF, or kidney failure Signs and Symptoms Sudden, severe abdominal pain out of proportion of physical examination Nausea/vomitting 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 w/ Risk Factors for peripheral embolization Afib, recent MI, valvular Dz, atherosclerosis Angiography Treatment TPA hemolytic agents during angiography – TPA = clot busting drugs 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 bowl resection, which is associated with a 15x increase in mortality Late diagnosis w/ bowel necrosis results in death for 70 – 90% Massage ABSOLUTE CONTRAINDICATION Intestinal ischemia is a medical emergency – requires immediate medical attention Intestinal Atresia: Congenital, complete obstruction of intestinal lumen Malformation during development – body didn’t form tube correctly Presentation Abdominal distention and bilious emesis in first w days of life Bilious emesis – vomiting with bile Treatment Surgical resection with anastomosis of uninvolved segments Massage N/A Will be treated in first few days of life Meckel's Diverticulum: Congenital outpouching of the intestine due to a remnant of embryonic connection b/w the intestine and umbilicus Usually an appendage of the ileum Most common malformation of the GI traction Often asymptomatic and undiagnosed Can become filled with food or fecolith and become infected or rupture Symptoms Usually asymptomatic Rectal bleeding, epigastric and LLQ pain, nausea Complications 1. Intestinal obstruction 2. Volvulus 3. Intussusception Treatment Surgical removal Massage LOCAL CI Hirschsprung's Disease: 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 Complications 1. Megacolon – different from toxic megacolon 2. Intestinal obstruction 3. Perforation volvulus 4. Intussusception Treatment Colostomy May need long term high fibre diet and/or laxatives Massage LOCAL CI Intussusception: Aka telescoping An intestinal disorder in which a segment of the intestine folds in on itself Serious complications: Intestinal obstruction Vascular blockage and tissue infarction Most commonly occurs in the ileocecal region 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 tumour Etiology Children – more common, most cases are idiopathic Risk factors: Meckel's diverticulum, Hirschsprung's disease, intestinal malrotation, family Hx Adults – abnormal growth, such as polyp or tumour Acts as "leading edge" to pull bowel into itself Signs & Symptoms Intermittent abdominal pain, vomiting in an otherwise healthy child, palpable mass in abdomen Children may guard abdomen: knees to chest position Complications 1. Intestinal obstruction on volvulus 2. Ischemia and infarction Causes sloughing of tissue Results in intestinal mucosa, blood, and mucus in stool: red, jelly-like stool 3. Perforation and peritonitis 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 Massage ABSOLUTE CONTRAINDICATION Intussusception is a medical emergency – requires immediate medical attention Volvulus: Twisting of a loop of intestine around itself and its surrounding mesentery Serious complications: Intestinal obstruction Vascular blockage and tissue infarction – can lead to perforation and peritonitis M/C affected are is the sigmoid colon Also affects the cecum and midgut Etiology 1. Pregnancy Fetus causes displacement and twisting of colon 2. Constipation Stool acts as pivot point for intestine to twist around 3. 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 4. Hirschsprung's Disease Signs & Symptoms Severe abdominal pain Abdominal distention Constipation, bloody stool, vomiting Diagnosis X-ray (w/ or w/out barium) Treatment Sigmoidscopy Tubes able to relieve pressure and untwist colon Surgical resection if infarction occurs Massage ABSOLUTE CI Medical emergency – required immediate medical attention Strangulation: Trapping and cutting off of blood supply to intestinal tissue Etiology 1. Herniation 2. Intestinal obstruction 3. Volvulus 4. Intussusception Signs & Symptoms Steady, severe pain with fever Complications Gangrene – tissue damage w/ significant putrefaction Can develop in as few as 6 hours Often causes rupture that leads to peritonitis, shock, and – if untreated – death Massage ABSOLUTE CI Medical emergency – required immediate medical attention Familial Adenomatous Polyposis: 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 Only needs 1 parent with the allele – 50% change of getting it Benign – but a tiny change of it becoming not benign Signs & Symptoms Often asymptomatic Rectal and/or occult bleeding 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 Massage No CI's Colorectal Carcinoma: Adenocarcinomas that develop in glandular intestinal lining of the colon or rectum Usually begins as benign polyp Due to large lymph supply and vascular relationship to liver, early metastasis to these organs is common Epidemiology Third most common cancer worldwide Second leading cause of cancer deaths in western countries More common in males 1/16 males and 1/18 females will develop colorectal cancer Women are more prone to colon CA Men are more prone to rectal CA Risk Factors Family history of colorectal cancer and FAP Ulcerative colitis and, to a lesser degree, Crohn's disease High fat, low fibre diet Smoking and alcohol Signs & Symptoms Generally slow growing w/o symptoms in early disease First sign – usually blood in stool A change in bowl habits, such as more frequent diarrhea or constipation Possible bowel obstruction Ongoing discomfort in the belly area, such as cramps, gas or pain 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 2 years for average risk Colonoscopy 40 or 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 Treatment Surgical resection of colon and local lymph is primary treatment Curative in 90% of cases when CA is only lining the bowl 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 permanent colostomy Massage No contraindications