Mosby s PATHOLOGY for Massage Therapists Chapter 11 Gastrointestinal Pathologies Lesson 11.1 Objectives Discuss anatomic structures and physiologic processes related to the gastrointestinal system. Define general dysfunctions of the gastrointestinal tract and list appropriate massage considerations for each. 2 Classes of Nutrients Building Blocks of Nutrients Carbohydrates Proteins Lipids (fats) Vitamins Minerals Water Carbohydrates Deconstruct to monosaccharides or simple sugars Proteins Deconstruct to amino acids Fats Deconstruct to glycerol and fatty acids 3 4 Gastrointestinal Structures Peritoneum From Thibodeau GA, Patton KT: The human body in health and disease, ed 4, St. Louis, 2005, Mosby. From Thibodeau GA, Patton KT: Anatomy & physiology, ed 6, St. Louis, 2007, Mosby. 5 6
7 Abdominal Area Abdominal quadrants and regions Digestive Functions Ingestion Secretion Mixing and propulsion (peristalsis) Digestion Absorption Defecation From Lewis SL et al: Medical surgical nursing, ed 7, St. Louis, 2007, Mosby. 8 Digestive Process Digestive Process (cont (cont d.) Begins in the mouth Food, now a bolus, moves to the stomach Stomach grinds and mixes bolus with gastric juices Bolus, now chyme,, moves to the small intestine Chyme moves through to the colon for final absorption and defecation Liver produces bile Pancreas produces enzymes Gallbladder stores excess bile These products enter the small intestine via ducts Absorption into blood and lymph Blood circulates nutrients to cells of body 9 10 General Dysfunctions of GI Tract Nausea Nausea Vomiting Constipation Diarrhea Unpleasant subjective experience often leading to an urge to vomit; often called sick to the stomach, upset stomach, or queasiness Modify massage according to cause (pregnancy, GI infection); in most cases, use a semireclining position and avoid pressure and speed that causes rocking 11 12
13 Vomiting Constipation Reflexive, forceful emptying of stomach and intestinal contents through the mouth ; if vomiting occurs during session, treat vomitus as infectious Infrequent or difficult passing of stools Modify massage according to cause (IBS, diverticulitis); in most cases, apply circular gliding strokes, kneading and vibration in a clockwise direction on abdomen 14 Constipation (cont (cont d.) Diarrhea Frequent passing of unformed, loose, watery stools in acute cases; chronic cases might entail suggested use of toilet before massage and avoidance of lower abdomen 15 16 Lesson 11.2 Objectives Diseases of the Upper GI Tract Name various diseases of the upper gastrointestinal tract and state appropriate massage considerations. Discuss diseases of the lower gastrointestinal and appropriate massage considerations. Contrast and compare ulcerative colitis with Crohn disease. Explain how to accommodate clients who have had a colostomy or ileostomy. Mumps Thrush Tonsillitis Gastroesophageal reflux disease Peptic ulcer disease Gastritis Gastroenteritis 17 18
19 Mumps Thrush Viral infection leading to enlargement of one or both parotid glands Fungal infection of the oral mucosa Avoid prone position if it produces facial pain; avoid lower portion of face Courtesy Dr. GDW McKendrik. In Zitelli BJ, Davis HW: Atlas of pediatric physical diagnosis, ed 3, St. Louis, 1997, Mosby. From Zitelli BJ, Davis HW: Atlas of pediatric physical diagnosis, ed 4, St. Louis, 2002, Mosby. 20 Tonsillitis, Acute Gastroesophageal Reflux Disease Inflammation of the tonsils Periodic regurgitation of gastric contents into the esophagus; causes heartburn Use semireclining position; avoid chest and upper abdomen if sensitive From Forbes CD, Jackson WF: A color atlas and text of clinical medicine, London, 1993, Mosby Europe. 21 22 Peptic Ulcer Disease Ulcerations of the mucosal lining in GI tract exposed to acidic gastric juice Use semireclining position; avoid abdomen if sensitive From Fletcher CDM, Mckee PH: An atlas of gross pathology, London, 1987, Gower Medical Publishing. Inflammation of gastric mucosa in acute cases; otherwise, use semireclining position and avoid abdomen Gastritis From Damjanov I, Linder J: Pathology: a color atlas, St. Louis, 2000, Mosby. 23 24
25 Gastroenteritis Diseases of the Lower GI Tract Inflammation of the lining of the gastric and intestinal mucosa; also known as stomach flu Polyps Diverticulosis Diverticulitis Irritable bowel syndrome Ulcerative colitis Crohn disease Intestinal obstruction Appendicitis Hemorrhoids 26 Polyps, Colorectal Diverticulosis Benign growths on mucous membranes; commonly found in colon Avoid abdomen if sensitive Presence of diverticula (herniations)) in the colon wall Avoid abdomen if sensitive Courtesy David Bjorkman,, M.D., University of Utah School of Medicine, Department of Gastroenterology. In McCance KL, Heuther SE: Pathophysiology: : the biologic basis for disease in adults and children, ed 5, St. Louis, 2006, Mosby. From Damjanov I, Linder J: Pathology: a color atlas, St. Louis, 2000, Mosby; and Modified from Stevens A, Lowe J: Pathology, ed 2, London, 2000, Mosby. 27 28 Diverticulitis Irritable Bowel Syndrome Infection in the diverticula Abnormal muscular contraction of large intestine and excessive mucus in stools Focus on relaxation during massage while avoiding the abdomen if sensitive From Frazier MS, Drzymkowski J: Essentials of human diseases and conditions, ed 3, Philadelphia, 2004, WB Saunders. 29 30
31 Ulcerative Colitis Inflammation of the colon; usually begins in the rectum and then spread proximally, eventually involving the entire colon Periods of remission and exacerbation Avoid the abdomen Crohn Disease Chronic irritable bowel disease that affects any part of GI tract Characterized by skip lesions Periods of remission and exacerbation Avoid the abdomen From Cooke RA, Stewart B: Colour atlas of anatomical pathology, ed 3, Sydney, 2004, Churchill Livingstone. From Damjanov I: Pathology for the health-related professions, ed 2, Philadelphia, 2000, WB Saunders. 32 Ulcerative Colitis vs. Crohn Disease Ulcerative Colitis vs. Crohn Disease (cont (cont d.) 33 34 Colostomy and Ileostomy Colostomy and Ileostomy (cont (cont d.) Colostomy Incision in colon Ileostomy Incision in small intestine (usually the ileum) Both procedures are used to create an opening that is affixed to exterior abdominal wall Ask client not eat 2-32 3 hrs before session Do not apply lubricant on or near bag opening Include use of a side lying position From Salvo S: Massage therapy: principles and practice, ed 2, Philadelphia, 2003, WB Saunders. From Salvo S: Massage therapy: principles and practice, ed 2, Philadelphia, 2003, WB Saunders. 35 36
37 Intestinal Obstruction Any blockage of the intestines; Small intestine most often involved Inflammation of the vermiform appendix Appendicitis, Acute From Gould BE: Pathophysiology for the health professions, ed 3, St. Louis, 2006, Saunders. 38 Hemorrhoids Lesson 11.3 Objectives Dilated and inflamed anal or rectal veins Position client for comfort; this usually involves avoiding semireclining and seated positions Identify diseases of the liver, gallbladder, and pancreas and list appropriate massage considerations. Delineate types of viral hepatitis. Discuss disorders of nutrient and absorption and include appropriate massage considerations. Discuss other gastrointestinal disorders and list appropriate massage considerations. From Lewis SM, Heitkemper MM, Dirksen SR: Medical-surgical nursing: assessment and management of clinical problems, ed 7, St. Louis, 2007, Mosby. 39 40 Diseases of the Liver, Gallbladder, and Pancreas Jaundice Viral hepatitis Cirrhosis Cholelithiasis Cholecystitis Pancreatitis Jaundice Yellowish color of skin and mucosa caused by elevated blood bilirubin levels From Damjanov I: Pathology for the health professions ed 3, St. Louis, 2006, Saunders. 41 42
43 Viral Hepatitis Inflammation of the liver Modify massage according to symptoms; avoid abdomen and deep pressure as client may bruise easily Types of Hepatitis Modes of transmission: Type A (HAV): oral-fecal contact, contaminated food or water Type B (HBV): sexual contact, blood contact, mother to baby during birth Type C (HCV): blood contact, mother to baby during birth Type D (HDV): sexual contact, blood contact, mother to baby during birth 44 Cirrhosis Cholelithiasis Progressive disease that destroys liver cells in later stages (indicated by jaundice); avoid deep pressure over abdomen and areas of pitting edema Formation and presence of gallstones if symptoms are severe; otherwise, avoid abdomen A, from Stevens A, Lowe J: Pathology, ed 2, London, 2000, Mosby. Modified from Fazier MS, Drzymkowski JW: Essentials of human diseases and conditions, ed 2, Philadelphia, 2000, WB Saunders. 45 46 Cholecystitis Pancreatitis Inflammation of the gallbladder and cystic duct in acute cases or if fever is present; otherwise, avoid abdomen Inflammation of the pancreas in acute cases; otherwise, avoid abdomen From Fletcher CDM, Mckee PH: An atlas of gross pathology, London, 1987, Gower Medical Publishing. From Damjanov I: Pathology for the health-related professions, ed 2, Philadelphia, 2000, WB Saunders. 47 48
49 Diseases of Nutrient Intake and Malabsorption Anorexia nervosa Bulimia Obesity Celiac disease Food poisoning Anorexia Nervosa Refusal to maintain normal body weight for person s s age and height; both an eating and emotional disorder Reduce treatment time and pressure if client is fatigued; use a warm blanket From Forbes CD, Jackson WF: A color atlas and text of clinical medicine, London,1993, Mosby Europe. 50 Bulimia Obesity Continuous eating (bingeing) followed by recurrent inappropriate compensatory behaviors to prevent weight gain Primary method is self- induced vomiting called purging Reduce treatment time and pressure if client is overly fatigued Increase in the proportion of fat cells Body weight is 30% above normal for age, height, frame size, and gender Associated with leading causes of death in U.S.: cardiovascular disease, type II diabetes, and cancer From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM, Philadelphia, 2000, WB Saunders. 51 52 Massaging the Larger Client Celiac Disease Lower table or use floor mat Use sheet draping Avoid deep pressure over adipose tissue or over loose skin Hypersensitivity to gluten in dietary grains Modify massage according to symptoms; avoid abdomen if sensitive From Salvo S: Massage therapy: principles and practice, ed 3, St. Louis, 2007, Saunders. 53 54
55 Food Poisoning Other GI Disorders Illness resulting from consuming contaminated food or beverages Often due to bacteria Peritonitis Hernias Hiatal Umbilical Inguinal Femoral 56 Other GI Disorders: Peritonitis Inflammation of the peritoneum Hernias Protrusion of tissues or organs through weakness in a membranous or cavity wall Four most common types: hiatal,, inguinal, femoral, umbilical From Frazier MS, Drzymkowski JW: Essentials of human diseases and conditions, ed 2, Philadelphia, 2000, WB Saunders. From Leonard, PC: Building a medical vocabulary, ed 6, Philadelphia, 2005, WB Saunders. 57 58 Hiatal Hernia Umbilical Hernia Protrusion of upper part of the stomach through diaphragm Avoid abdomen if sensitive Protrusion of intraabdominal contents through weakness around umbilicus Avoid abdomen if sensitive From Redrawn from Price SA, Wilson LM: Pathophysiology: : clinical concepts of disease processes, ed 6, St. Louis, 2003, Mosby. In Lewis SL et al: Medical surgical nursing, ed 7, St. Louis, 2007, Mosby. 59 A, from Frazier MS, Drzymkowski JW: Essentials of human diseases and conditions, ed 2, Philadelphia, 2000, WB Saunders; B, from Zitelli BJ, Davis HW: Atlas of pediatric physical diagnosis, ed 3, St. Louis, 1997, Mosby. 60
61 Inguinal Hernia Femoral Hernia Protrusion of intestine through the inguinal canal if severe pain is present; otherwise, position the client for comfort Protrusion of intestine through the femoral canal if severe pain is present; otherwise, avoid medial thigh if sensitive From Seidel H: Mosby s s guide to physical examination, ed 5, St. Louis, 2003, Mosby. A, from A, Frazier MS, Drzymkowski JW: Essentials of human diseases and conditions, ed 2, Philadelphia, 2000, WB Saunders; B, from Zitelli BJ, Davis HW: Atlas of pediatric physical diagnosis, ed 3, St. Louis, 1997, Mosby. 62