1
Q
Irritable Bowel Syndrome (IBS)
Definition
Disorder of, Unlike IBD, “Functional disorder”
A
- 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
2
Q
Irritable Bowel Syndrome (IBS)
Epidemiology
% of population, gender, age, brain-gut axis
A
- Affects ~15% of population and women are slightly more at risk
- Usually begins in mid – 20s, most cases start prior to 35 yo
- People with 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)
3
Q
Irritable Bowel Syndrome (IBS)
Etiology
Visceral hypersensitivity, risk factors, triggers
A
- 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
4
Q
Irritable Bowel Syndrome (IBS)
Signs and Symptoms
A
- 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
5
Q
Irritable Bowel Syndrome (IBS)
The Bristol Stool Chart
A
- 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
6
Q
Irritable Bowel Syndrome (IBS)
Diagnosis
A
- 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
7
Q
Irritable Bowel Syndrome (IBS)
Treatment
A
- 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
8
Q
Irritable Bowel Syndrome (IBS)
Common triggers, dairy and gluten, FODMAPS
A
- Common triggers include fatty foods, fried foods, highly processed foods and some of the foods in the chart to the right
- 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
9
Q
Irritable Bowel Syndrome (IBS)
Massage and Irritable Bowel Syndrome (IBS)
A
- possible LOCAL CONTRAINDICATION
- Avoid the abdomen during massage if it causes the patient discomfort
10
Q
Diverticulosis
Definition
Diverticula, True diverticula, pseudo, MC affected area
A
- 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
11
Q
Diverticulosis
Definition
Affects areas where
A
- Affects areas where vessels traverse muscle layer (ie. where the vasa recta penetrate the circular muscle layer of the colon)
12
Q
Diverticulosis
Epidemiology
A
- Prevalence is age dependent, increased risk with increased age
- Less than 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
13
Q
Diverticulosis
Etiology
High pressure where, theories, genetic CT disorders
A
- 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)
14
Q
Diverticulosis
Signs and Symptoms
A
- Usually asymptomatic unless complications occur
- Often an incidental finding on colonoscopy
- Vague abdominal pain, BM irregularity
15
Q
Diverticulosis
Complications
3 complications if diverticula worsens
A
- 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
16
Q
Diverticulosis
Complications
* Diverticulitis (1-4% of pt)
A
- 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
17
Q
Diverticulosis
Complications
Diverticular bleeding (5-15% of pt)
A
- 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
18
Q
Diverticulosis
Diagnosis
A
- 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
19
Q
Diverticulosis
Treatment
A
- 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
20
Q
Diverticulosis
Massage and Diverticulosis
A
- possible LOCAL CONTRAINDICATION
- Avoid the abdomen during massage if it causes the patient discomfort
- For patients with diverticulitis, avoid massage until
the condition has been treated
21
Q
Hemorrhoids
Definition
A
- 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
22
Q
Hemorrhoids
Etiology
A
- 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
23
Q
Hemorrhoids
Signs and Symptoms
Internal, External hemorrhoids
A
- Internal hemorrhoids 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
24
Q
Hemorrhoids
Diagnosis
A
- Diagnosed via digital rectal exam (DRE) or visual inspection
25
# Hemorrhoids
Treatment
| Conservative tx, if conservative fails...
* 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
26
# Hemorrhoids
Massage and Hemorrhoids
* No contraindications
* Be cautious of patient positioning and comfort
27
# Appendicitis
Definition
| Inflammation of, MC surgical emergency, MC age group
* Inflammation of the vermiform appendix
* MC surgical emergency of abdomen (affects 10% of population)
* Incidence is highest in the 10-19 yo age group
28
# Appendicitis
Etiology
* Obstruction is the primary cause
* Fecolith
* Fibrosis
* Parasite infection
* Children: lymphoid hyperplasia d/t infection
29
# 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
30
# Appendicitis
Physical Examination
* McBurney’s sign
* Rovsing’s sign
* Psoas sign
* Obturator sign
* Positive rebound tenderness
* Abdominal guarding
31
# 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
32
# 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
33
# Appendicitis
Treatment
* For most (regardless if perforated or not), appendectomy followed by IV antibiotics
34
# Appendicitis
Massage and Appendicitis
* ABSOLUTE CONTRAINDICATION
* Patient needs emergent medical treatment
35
# Peritonitis
Definition
* Inflammation of the inner membrane that lines the abdominal cavity and abdominal organs
* Most commonly caused by secondary infection
36
# Peritonitis
Types (Classified based on etiology)
| Name 2 types, info about them, which more common
* **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
37
# Peritonitis
Signs and Symptoms
* Fever, N/V, chills
* Sudden, severe abdominal pain worse with movement
* Abdominal tenderness
38
# Peritonitis
Complications
* Dehydration, electrolyte imbalances, sepsis
39
# Peritonitis
Treatment
* Surgery to remove infected issue or drain fluid
* IV Antibiotics, and pain medications
40
# Peritonitis
Massage and Peritonitis
* ABSOLUTE CONTRAINDICATION
* Peritonitis is a medical emergency and requires
immediate medical attention
41
# Viral Gastroenteritis
Definition
* Viral infection of intestine that cause nausea, vomiting, and watery diarrhea
* “stomach flu”
42
# Viral Gastroenteritis
Etiology
| Rotavirus, Norwalk Virus
* **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
43
# Bacterial Gastroenteritis
Definition
* Loose stools caused by various bacterial infections
* Bacteria invade and colonize intestine, then cause inflammation and destroy tissue
44
# Bacterial Gastroenteritis
Etiology
| Bacterial toxins, Lytic Bacteria, Invasive bacteria
* **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
45
# Protozoal Enteritis
Definition
* Parasitic infection of the intestine
* Common in those traveling to southern countries
46
# Protozoal Enteritis
Etiology
| Giardia lambia, Entamoeba histolytica
* **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
47
# Infectious Diseases
Massage and Infectious Diseases
* CONTRAINDICATION
* Patients should not be in your office if they are feeling unwell
48
# Intestinal Ischemia
Definition
* A group of disorders that result from compromised blood flow in segments of the intestine (can affect LI or SI)
49
# Intestinal Ischemia
Etiology
| Any process that does what, acute, chronic
* 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
50
# Intestinal Ischemia
Ischemic Colitis
| Definition
* blood flow to part of the colon is slowed or blocked
51
# Intestinal Ischemia
Ischemic Colitis
| Etiology
* Hypotension (shock or severe dehydration)
* Atherosclerosis or thrombosis
* Volvulus or incarceration
52
# Intestinal Ischemia
Acute Mesenteric Ischemia
| Definition
* Sudden onset of small intestinal hypoperfusion
53
# Intestinal Ischemia
Acute Mesenteric Ischemia
| 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
54
# 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
55
# Intestinal Ischemia
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
56
# 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
57
# Intestinal Ischemia
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%
58
# Intestinal Ischemia
Massage and Intestinal Ischemia
* ABSOLUTE CONTRAINDICATION
* Intestinal ischemia is a medical emergency and
requires immediate medical attention
59
# Intestinal Atresia
Definition, Presentation, Treatment
**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
60
# Intestinal Atresia
Massage and Intestinal Atresia
* N/A
* Will be treated in first few days of life
61
# 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
62
# Meckel’s Diverticulum
Symptoms
* Usually asymptomatic
* Rectal bleeding, epigastric and LLQ pain, nausea
63
# Meckel’s Diverticulum
Complications, Treatment
**Complications**
* Intestinal obstruction, volvulus, and/or intussusception
**Treatment**
* Surgical removal
64
# Meckel’s Diverticulum
Rule of 2's
* 2% of population
* M:F ration 2:1
* 2 feet from ileocecal valve
* 2 inches in length
* 2% develop complications (50 percent die by age 2)
65
# Meckel’s Diverticulum
Massage and Meckel’s Diverticulum
* LOCAL CONTRINDICATION
66
# 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
67
# Hirschsprung’s Disease
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
68
# Hirschsprung’s Disease
Complications
* Megacolon, intestinal obstruction, perforation volvulus, and/or intussusception
69
# Hirschsprung’s Disease
Treatment
* Temporary colostomy
* May need long term high fiber diet and/or laxatives
70
# Hirschsprung’s Disease
Massage and Hirschsprung’s Disease
* LOCAL CONTRAINDICATION
71
# 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
72
# 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
73
# Intussusception
Etiology
| Children, Adults
* 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
74
# Intussusception
Signs and Symptoms
* Intermittent abdominal pain, vomiting in an otherwise healthy child, palpable mass in abdomen
* Children may guard abdomen: knees to chest position
75
# 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
76
# Intussusception
Diagnosis
* Abdominal US or CT shows “bulls eye”
77
# Intussusception
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
78
# Intussusception
Massage and Intussusception
* ABSOLUTE CONTRAINDICATION
* Intussusception is a medical emergency and requires
immediate medical attention
79
# 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
80
# 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**
81
# Volvulus
Signs and Symptoms
* severe abdominal pain
* Abdominal distention
* constipation, bloody stool, vomiting
82
# Volvulus
Diagnosis, Treatment
**Diagnosis**
* X-ray (w/ or w/o barium)
* Will show Coffee Bean sign
**Treatment**
* Sigmoidoscopy
* Tubes able to relieve pressure and untwist colon
* Surgical resection if infarction occurs
83
# Volvulus
Massage and Volvulus
* ABSOLUTE CONTRAINDICATION
* Volvulus is a medical emergency and requires
immediate medical attention
84
# Strangulation
Definition, Etiology
**Definition**
* Trapping and cutting off of blood supply to intestinal tissue
**Etiology**
* Herniation, intestinal obstruction, volvulus, intussusception
85
# Strangulation
S&S, Complications
**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
86
# Strangulation
Massage and Strangulation
* ABSOLUTE CONTRAINDICATION
* Strangulation is a medical emergency and requires immediate medical attention
87
# 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
88
# Familial Adenomatous Polyposis
Signs and Symptoms
* Often asymptomatic
* Rectal and/or occult bleeding
89
# 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
90
# Familial Adenomatous Polyposis
Treatment
* Colectomy at time of diagnosis
* May or may not leave rectal remnant
* If left, requires biyearly screening
91
# Familial Adenomatous Polyposis
Massage and Familial Adenomatous Polyposis
* No contraindication
92
# 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 metastasis to these organs is common
93
# 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
* Women are more prone to colon CA and men are more prone to rectal CA
94
# 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
95
# Colorectal Carcinoma
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
96
# 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
97
# 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
98
# 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. <1% five year survival rate
99
# Colorectal Carcinoma
Massage and Colorectal Carcinoma
* No contraindication
700 - Sys Path
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