1
Q
Cholelithiasis (Gallstones)
Definition
A
- “chole” = bile or gall, “lithiasis” = stones
- Collections of solid material in the gallbladder
- Can be dislodged and get stuck in the cystic duct, common bile duct, hepatopancreatic ampulla
2
Q
Cholelithiasis (Gallstones)
Epidemiology
A
- More common in Indigenous and Hispanic populations
- In Canada 70-80 percent of the First Nations population is affected with this disease
- More common in females than males
- Gallstones occur in up to 20% of Canadian women and 10% of men by the age of 60
3
Q
Cholelithiasis (Gallstones)
Risk factors
A
- Used formerly to describe patient: “Four F’s” of gallstones:
- Female, Forty, Overweight, and Fertile
- Other risk factors: SAD diet, family history
4
Q
Cholelithiasis (Gallstones)
- Two main types of stones
- Most common stones
A
- Two main types of stones
- Cholesterol stones
- Pigment stones
- Most common stones: cholesterol stones
- Cholesterol is a lipid that is created in liver and dissolves in bile
- If liver secretes excess, bile becomes oversaturated and crystals
can form - Excess hemolysis can form pigment stones made of bilirubin
5
Q
Cholelithiasis (Gallstones)
Signs and Symptoms
A
- 80% have no S/S and the gallstones remain in the gallbladder
- As stone passes from gallbladder into the cystic duct, common bile duct, and/or hepatopancreatic ampulla, GB swells and causes colicky RUQ pain
6
Q
Cholelithiasis (Gallstones)
Signs and Symptoms
Pain Patterns
A
- Pain patterns (“gallbladder attack”)
- Pain is diffuse and hard to localize (usually RUQ or epigastric)
- Can radiate to right shoulder or between scapulae
- Increases over 15 minutes then plateaus at about 30-60 min
- Most episodes last < 6 hrs but can last up to 12 hrs
- Usually severe enough to go to ER
7
Q
Cholelithiasis (Gallstones)
Complications and Diagnosis
A
- Complications
- Cholecystitis
- Diagnosis
- Abdominal ultrasound
8
Q
Cholelithiasis (Gallstones)
Treatment
A
- No treatment required if there are no S/S
- Even early episodes with S/S will watch and wait
- Disruptive, recurring episodes often result in laparoscopic cholecystectomy
- Usually little to no effect on digestion
- May increase transit time of bowel
- Low fat diet to reduce strain on gallbladder
- Some evidence suggests extremely low fat diets may increase gallstone formation
9
Q
Massage and Cholelithiasis
A
- No absolute contraindications for patients that currently have or have had cholelithiasis
- However, if S/S of obstruction are present (N/V, colicky RUQ pain), then massage is CONTRAINDICATED
10
Q
Cholecystitis
Definition
A
- Inflammation of the gallbladder, typically occurs in those with a Hx of symptomatic gallstones
- Blockage of cystic duct by gallstones causes inflammation of the gallbladder
- Can be acute or chronic
11
Q
Cholecystitis
Etiology
A
- Secondary to gallstones is most common
- Other causes include tumors, certain viral infections
12
Q
Cholecystitis
Acute Cholecystitis
A
- Sudden, severe, steady pain in the RUQ
- Most common cause: gallstones (95%)
- Acalculous cholecystitis is rare, but more serious and is r/t major surgery, severe burns, sepsis, prolonged parenteral nutrition, prolonged fasting
- Gallbladder fills with fluid and walls thicken
- Can occur in children and adults
13
Q
Cholecystitis
Chronic Cholecystitis
A
- Chronic inflammation of the gallbladder w/ repeated attacks of biliary colic (abdominal pain caused by blocked bile duct)
- Most common cause: gallstones
- Gallbladder becomes thick- walled, scarred, and small
- Gallbladder contains sludge and/or stones that block the opening to the cystic duct or the duct itself
14
Q
Cholecystitis
Signs and Symptoms
A
- RUQ colicky pain that lasts 6-12 hours or more and is quite severe
- Pain peaks at 15-60 minutes and remains constant
- Can spread to right shoulder or between scapulae
- Increased pain with deep breaths
- Nausea and vomiting common
- (+) Murphy’s sign (not diagnostic, but provides useful information)
- May have abdominal rigidity and guarding
- In acute, ~1/3 have fever of over 38°C and chills
15
Q
Cholecystitis
Diagnosis
A
- US is best way to detect gallstones, fluid around GB, and thickening of GB walls
16
Q
Cholecystitis
Treatment
A
- Hospitalization is likely
- Intravenous (IV) fluids while your digestive
system rests - IV antibiotics to treat or prevent infections
- IV analgesics
- Definitive treatment for both acute and chronic
cholecystitis is cholecystectomy
17
Q
Massage and Cholecystitis
A
- ABSOLUTE CONTRAINDICATION for acute cholecystitis and severe chronic cholecystitis
18
Q
Primary Biliary Cholangitis
Definition
A
- Autoimmune disease causing inflammation and destruction of the bile ducts in the liver
- Previously known as primary biliary cirrhosis
19
Q
Primary Biliary Cholangitis
Epidemiology
A
- Incidence rates range from 0.33 to 5.8 per 100,000 inhabitants/year
- Women are predominantly affected with a sex ratio of 9:1
- Onset is generally in the 4th to 6th decades of life
20
Q
Primary Biliary Cholangitis
Etiology
A
- Autoimmune disease
- Thought to be a combination of genetic and environmental factors that triggers the disease
21
Q
Primary Biliary Cholangitis
Signs and Symptoms
A
- More than half of people diagnosed are asymptomatic at the time
- Incidental findings on blood tests
- Symptoms eventually develop over the next 5 to 20 years and include:
- Fatigue, itchy skin, jaundice, RUQ pain, edema
- Complications include cirrhosis
22
Q
Primary Biliary Cholangitis
Diagnosis
A
- LFTs
- Antibody serology
- Blood tests may be done to check for anti-mitochondrial antibodies
(AMA) which are very common in PBC - Imaging
- Ultrasound
- Special type of MRI to view structure of bile ducts
- Liver biopsy may be needed to confirm
23
Q
Primary Biliary Cholangitis
Treatment
A
- No cure for primary biliary cholangitis
- Medications available to help slow the progression of the disease
- Ursodeoxycholic acid (UDCA or ursodiol)
- Helps move bile through your liver
- Improves liver function and reduce liver scarring
- Symptomatic treatment of itching and fatigue (antihistamines)
- Liver transplant may be necessary
24
Q
Primary Biliary Cholangitis
Prognosis
A
- Once S/S develop the average life expectancy is about 10 years
- Successful liver transplants offer a 10-year survival rate of 65%
25
# Primary Sclerosing Cholangitis
Definition
* Inflammatory disease of the bile ducts, both intrahepatic and extrahepatic
* Scarring of the ducts causes narrowing, which gradually causes serious liver damage
26
# Primary Sclerosing Cholangitis
Etiology
* Cause is unclear
* Immune system reaction to infection or toxin may be trigger in people who are genetically predisposed to it
* Large proportion also have IBD
27
# Primary Sclerosing Cholangitis
Epidemiology
* Fairly rare disease
* Estimated incidence of 1 per 100,000 per year (Europe and NA)
* Can occur at any age, median age of diagnosis of 41
* More common in males than females
* More common in people of Northern European descent
28
# Primary Sclerosing Cholangitis
Signs and Symptoms
* Usually asymptomatic at diagnosis
* Early signs and symptoms include:
* Fatigue
* Itching
* Jaundice
* RUQ pain
* Complications include cirrhosis and liver failure
29
# Primary Sclerosing Cholangitis
Diagnosis
* LFTs
* Imaging
* Ultrasound
* Special type of MRI to view structure of bile ducts
* Liver biopsy may be needed to confirm
30
# Primary Sclerosing Cholangitis
Treatment
* No cure for primary sclerosing cholangitis
* medications available to help slow the progression of the disease
* Ursodeoxycholic acid (UDCA or ursodiol)
* helps move bile through your liver
* improves liver function and reduce liver scarring
* Symptomatic treatment of itching and fatigue (antihistamines)
* Liver transplant may be necessary
31
# Primary Sclerosing Cholangitis
Prognosis
* Once S/S develop the average life expectancy is between 10 and 20 years
* Successful liver transplants can lengthen life expectancy
* PSC returns in 15/20% of patients post transplant
32
# Pancreatitis
Definition
* Inflammation of the pancreas that can be mild
or life threatening
* Causes the activation and possible release of
enzymes
* Begin digesting and attacking the pancreas
* Possibly other tissues if they enter the bloodstream
* May be acute or chronic
33
# Pancreatitis
Etiology
* Most common causes of pancreatitis are:
* Alcoholism (chronic pancreatitis)
* Gallstones (acute pancreatitis)
* Alcohol is linked to 80% of pancreatitis cases
* Smoking has also been linked to chronic pancreatitis
34
# Pancreatitis
Acute Pancreatitis
* Most common cause is gallstones
* Think of acute pancreatitis as an event
* Acute attacks often precipitated by alcoholic binge, smoking or excessively large meal
* More common in females than males
35
# Pancreatitis
Chronic Pancreatitis
* Most common cause is alcohol
* Think of chronic pancreatitis as an ongoing process of pathologic response to pancreatic injury
* More common in males than females
36
# Pancreatitis
Signs and Symptoms
| LUQ pain, Gallstones (acute), Alcohol (chronic)
* Severe epigastric and LUQ pain that often radiates to the back
* **Gallstones (acute)**
* Pain starts suddenly and reaches max intensity in 10-20 min
* Acute onset of persistent, severe LUQ
* **Alcohol (chronic)**
* Pain onset is less abrupt
* Pain is poorly localized
37
# Pancreatitis
Signs and Symptoms Cont’d
| Aggravating factors, partial relief
* Aggravating factors: coughing, deep breathing, and vigorous movement
* Partial relief: sitting up or bending forward
* 90% have nausea/vomiting which may persist for several hours
* Tenderness of epigastrium (severity of pain depends on severity of pancreatitis)
38
# Pancreatitis
Diagnosis of Acute Pancreatitis
* Characteristic pain leads pancreatitis suspicion (acute onset of persistent, severe, epigastric pain with tenderness on palpation on PE)
* Blood tests support diagnosis:
* Increased serum lipase and amylase (3x)
* Leukocytosis
* US: pancreas may appear diffusely enlarged, gallstones may be visualized
39
# Pancreatitis
Treatment
| mild/severe usually requires, chronic, acute
* Whether mild or severe, usually requires hospitalization
* For chronic pancreatitis:
* Analgesics and antioxidants (E, C, selenium, methionine) for pain control
* Pancreatic enzyme supplementation
* For acute pancreatitis:
* Fasting, IV fluids, analgesics, and antiemetics
* Can resume normal eating w/in 2-3 days w/o further Tx
* Must treat the underlying cause (alcohol, gallstones, etc…)
40
# Pancreatitis
Prognosis
* In most patients with acute pancreatitis, the disease is mild in severity and patients recover in 3-5 days without complications or organ failure
* Recurring attacks of acute pancreatitis = chronic pancreatitis
41
# Pancreatitis
Massage and Pancreatitis
| Acute pancreatitis, Chronic pancreatitis
* **Acute pancreatitis** is an ABSOLUTE CONTRINDICATION
* Medical emergency that requires treatment
* **Chronic pancreatitis** may be a possible LOCAL CONTRAINDICATION
* Avoid abdominal massage if pressure produces pain or
discomfort
42
# Cystic Fibrosis
Definition
* Multisystem genetic disorder that results in dysfunction of a protein (CFTR) that regulates water and chloride channels
* Water and chloride cannot leave cells and enter lumen, causing thick mucus build up
* Mainly affects lungs, but also effects liver, pancreas, and sweat glands
43
# Cystic Fibrosis
Definition
* Thickening of pancreatic secretions blocks the duct or even the gland completely, causing scarring of pancreas
* ~15% of persons with cystic fibrosis develop insulin-dependent diabetes due to inability to produce insulin
* Remember, pancreas is what produces insulin
44
# Cystic Fibrosis
Etiology and Epidemiology
**Etiology**
* Genetic disease
* Mutation of CFTR gene on the 7th chromosome
**Epidemiology**
* Affects over 4,400 Canadians or roughly 1 in 3,848 live births
* More common in Caucasians
45
# Cystic Fibrosis
Signs and Symptoms
* Symptomatic presentation in infants and children:
* Respiratory Sx
* Productive cough, repeated lung infections, chronic bronchitis
* Meconium ileus
* Pancreatic disease (pancreatitis, pancreatic insufficiency)
* Liver disease (cirrhosis, portal hypertension)
46
# Cystic Fibrosis
Symptomatic presentation in adulthood
* If presenting later in life, more likely to have atypical
symptoms
* More likely to present with GI symptoms, diabetes mellitus and infertility
47
# Cystic Fibrosis
Diagnosis
* Early diagnosis of cystic fibrosis happens through newborn screening programs
* Shortly after baby is born, a small blood sample is taken from baby and tested
* Sweat test
* High chloride in sweat (chloride can’t be transported into cells)
48
# Cystic Fibrosis
Treatment
* There is no cure for cystic fibrosis, but treatment can ease symptoms, reduce complications and improve quality of life
* The goals of treatment include:
* Preventing and controlling infections that occur in the lungs
* Removing and loosening mucus from the lungs
* Treating and preventing intestinal blockage
49
# Cystic Fibrosis
Prognosis
* Most children with CF stay in good health until they reach adulthood
* Lung disease eventually worsens to the point where the person is disabled and death is most often caused by lung complications
* The average lifespan for people with CF who live to adulthood is about 44 years
50
Massage and Cystic Fibrosis
* No contraindications, but some adjustments may be necessary
* Cystic Fibrosis Foundation recommends massage
techniques that may loosen mucus
* *DO NOT SEE PATIENTS IF YOU ARE ILL
51
# Carcinoma of the Pancreas
Definition
* Malignant tumours of the pancreas
* 95% of malignant tumors of the pancreas are adenocarcinomas
* Most commonly near pancreatic head
52
# Carcinoma of the Pancreas
Epidemiology
* 11th most common cancer in Canada, 4th amongst cancer-related deaths
* More common > 45 yo
* Slightly more common in males than females
53
# Carcinoma of the Pancreas
Etiology
* Environmental Risk Factors
* Smoking, chronic pancreatitis, DMII, obesity
* Hereditary Risk Factors
* Cystic fibrosis, FHx of pancreatic CA
54
# Carcinoma of the Pancreas
Signs and Symptoms
* Abdominal pain
* Abdominal pain is insidious in onset, gnawing in quality, generally epigastric
* Frequently worse at night, worse after eating, worse lying supine
* Jaundice
* Weight loss
* Pressure on pylorus of stomach resulting in vomiting
* Obstruction of small intestine
55
# Carcinoma of the Pancreas
Diagnosis
* Early dx is difficult d/t lack of SSx and PE/blood work often WNL
* Bloodwork done to evaluate for cholestasis and/or acute pancreatitis
* CT is preferred initial imaging test, but US and MRI sometimes used
* If pancreatic mass is seen on abdominal US, CT is next step
* Biopsy can be done for confirmation
56
# Carcinoma of the Pancreas
Prognosis
* Late stage diagnosis is common and metastasis is present in 90% of cases, resulting in a five year survival rate of 7%
57
# Carcinoma of the Pancreas
Treatment
* Pancreaticoduodenectomy (Whipple procedure) performed on those w/o metastasis
* Remove the head of the pancreas, the duodenum, gallbladder and bile duct
* 5 year survival ~20% after Whipple; 40% if no lymph involvement
* Chemotherapy and radiation are mostly palliative
58
Massage and Carcinoma of the Pancreas
* No contraindications
700 - Sys Path
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