Digestive System

Chapter 7 Digestive System Conditions: Introduction Trace a piece of food through the GI tract (Fig. 7.1): Mouth (teeth, tongue, saliva) Esophagus, lower esophageal valve Stomach, pyloric valve Small intestine • Duodenum, jejunum, ileum, ileocecal valve Large intestine • Cecum, ascending, transverse, descending, sigmoid colon Rectum Anus Chapter 7 Digestive System Conditions: Introduction Accessory organs: Liver • Bile, filter, blood proteins, clotting factors, anticoagulants… Gallbladder • Stores, concentrates bile, releases into small intestine Pancreas • Pancreatic juice, released into small intestine GI problems and massage: Common, non-dangerous problems can share symptoms with very dangerous problems; massage can give temporary relief, delaying an accurate diagnosis Any problem in a new pattern that persists for more than 2–3 weeks should be pursued with a primary care provider Gastroesophageal Reflux Disease (GERD) Damage to lining of the esophagus due to reflux of stomach contents (Fig. 7.3) Incidence Begins as heartburn; • 7%–10% in United States have heartburn daily • 40% have heart burn once/month Can happen at any age; most common in mature people Gastroesophageal Reflux Disease (GERD), cont. Mostly related to dysfunctional lower esophageal sphincter (LES): LES is too relaxed LES does not allow clearing of esophagus Low motility in stomach puts back-pressure on LES Gastroesophageal Reflux Disease (GERD), cont. Complications: Respiratory injury (gastric contents are inhaled) Ulcers in esophagus Stricture Barrett’s esophagus, risk of esophageal cancer Gastroesophageal Reflux Disease (GERD), cont. Risk Factors: Pregnancy Obesity Smoking Diet (fatty, acidic or spicy foods, caffeine…) Connective tissue diseases (lupus, scleroderma) Hiatal hernia Delayed stomach emptying (diabetes, paralysis) Others: radiation exposure, tumors, infection, some medications Gastroesophageal Reflux Disease (GERD), cont. Signs and symptoms: Heartburn, bloating, pain • Can mimic heart attack Dysphagia, coughing, wheezing Symptoms exacerbated by lying down Treatment: Management, repair • Change eating habits • Medication to reduce acidity, increase motility of stomach • Surgery to repair LES Gastroesophageal Reflux Disease (GERD), cont. Massage? Standard massage may exacerbate symptoms: • Increasing GI activity • Client lying down Make adjustments for client comfort: • Schedule around eating • Work on chair, semi-reclined, with head elevated • Avoid abdomen if necessary Esophageal Cancer Malignant cells in esophagus Proximal is squamous cell carcinoma (SCC) Distal is adenocarcinoma Incidence: African American men have most SCC Caucasian men have most adenocarcinoma Men > women, 8:1 13,500 diagnoses/year; 12,500 deaths 5-year survival < 5% Esophageal Cancer, cont. SCC: affects squamous epithelium of proximal and middle esophagus Related to smoking, drinking, both together Used to be the most common type of esophageal cancer Adenocarcinoma: affects distal portion of esophagus Usually begins as Barrett’s esophagus, a complication of GERD Now more common than SCC Esophageal Cancer, cont. Metastasis: Directly to nearby structures: • Trachea, diaphragm, aorta, vena cava Through lymphatics: • Lungs, liver, bones Through blood: • Uncommon Esophageal Cancer, cont. Risk factors: Age, gender race (uncontrollable) Tobacco, alcohol use (for SCC) GERD, Barrett’s esophagus (for adenocarcinoma) Other: exposure to poisons, radiation; hot beverages, vitamin deficiencies Esophageal Cancer, cont. Signs and symptoms: Early: none; often not palpable until after metastasis Later: mechanical obstruction, dysphagia, coughing, sometimes with blood Staging: Based on depth of infiltration, involvement of lymph nodes, and presence of distant tumors Esophageal Cancer, cont. Treatment: Surgery, chemotherapy, radiation, photodynamic therapy… Recovery is complicated by difficulties in eating Massage? Weigh benefits and risks according to the treatment options the client pursues; Work with health care team for best benefit (improved sleep, better eating, immune system resilience, parasympathetic effect) and minimal risks Ulcers Tissue damage with impaired healing Peptic ulcers of esophagus, stomach, small intestine have similar etiology to ulcers on the skin (Fig. 7.4) Incidence: 10% in the United States will have an ulcer at some time 25 million in the United States have been diagnosed 500,000–850,000 new diagnoses/year 1 million hospitalizations Men > women, 2:1 Ulcers, cont. Esophageal ulcers usually related to GERD Gastric, duodenal ulcers usually related to a combination of factors: Stress (moving in and out of stress, rather than being ―stuck‖ there) • Aggressive vs. defensive mechanisms; aggressive mechanisms recover from stress faster than defensive ones H. pylori infects most lesions (spirochete ―drills‖ into stomach lining) NSAIDs (specifically aspirin) damage stomach lining Ulcers, cont. Signs and symptoms: Gnawing, burning pain in abdomen • Relieved with antacids or eating Complications: Chronic bleeding can cause anemia Perforation can lead to peritonitis Stenosis can lead to obstruction Risk of stomach cancer increased 2–6× Also increased risk of lymphoma Ulcers, cont. Treatment: Antibiotics for H. pylori, bismuth, acid-reducers: 90% chance of full recovery Surgery if necessary • Vagotomy, stomach surgery Massage? As long as client is comfortable, massage is appropriate Be conservative in abdominal area Stomach Cancer Malignant tumors in stomach Incidence: 24,000 diagnoses/year United States 14,000 deaths/year Most 60–80 years old Men > women, 2:1 Stomach Cancer, cont. Most cases are adenocarcinomas May be related to high intake of salted, pickled, smoked foods (began to decline in United States after introduction of refrigeration) Related to infection with Helicobacter pylori Incompletely broken-down food may become carcinogenic; poor motility increases risk Undetectable in early stages; spreads to other abdominal organs directly, or liver through portal system Stomach Cancer, cont. Risk Factors: H. pylori infection Diet: salted, smoked, pickled foods, nitrates Tobacco, alcohol use Other: previous stomach surgery, type A blood, age, gender, genes associated with colorectal cancer Stomach Cancer, cont. Signs and symptoms: Develop only after tumor is large enough to obstruct movement • Fullness, abdominal pain, weight loss, heartburn, ascites, blood in stool Treatment: Radiation, chemotherapy, surgery 5-year survival rate approximately 20% Stomach Cancer, cont. Massage? Same guidelines as other clients with cancer: • Work with health care team to maximize benefits, minimize risks Gastroenteritis Inflammation of the stomach or small intestine Incidence: 100 million cases/year? (estimates) Approximately 10% seek medical attention 200,000 hospitalizations of children/year 10,000 deaths/year Gastroenteritis, cont. Causes: Viruses: Norwalk, rotaviruses, hepatitis, enteroviruses; highly contagious; 50%–70% of all cases (Not flu!) Bacteria: Salmonella, Shigella, Campylobacter, E. coli; contaminated food, water, ice Bacterial or viral gastroenteritis is sometimes called ―stomach flu‖ Others: Giardia, cryptosporidium, candidiasis, toxins, allergies, other GI disorders (Crohn disease, celiac disease, irritable bowel syndrome, etc. Gastroenteritis, cont. Signs and symptoms: When lining of GI tract is inflamed, it cannot function: nausea, vomiting, diarrhea Complications: Dehydration: leading cause of death from gastroenteritis Others: Guillain-Barré syndrome, meningitis, renal failure Gastroenteritis, cont. Diagnosis: Problematic: time and expense, some pathogens outlive symptoms Treatment: Often just fluids and rest, electrolyte replacement, good hygiene Antibiotics exacerbate symptoms, anti-diarrhea medications interfere with shedding mechanism Gastroenteritis, cont. Prognosis: Most clear up within 2–3 days Long-lasting cases indicate underlying pathologic condition Massage? Not during acute infection In chronic situations, gather information about underlying causes; massage may offer symptomatic relief Candidiasis Overgrowth of Candida albicans in digestive tract (Fig. 7.13) Incidence: Depends on the definition of the problem • Extreme version is most common in immunesuppressed population • Subtler version may be mistaken for allergies, hypothyroidism, other disorders Candidiasis, cont. Disruption in GI balance (with antibiotics, thymus tumors, hormonal imbalances) can lead to overgrowth of flora: candidiasis Signs and symptoms: Mouth lesions (thrush) Anal lesions (like diaper rash) Other skin lesions (affect nails, scalp too) Systemic symptoms (acute): fever, chills Systemic symptoms (chronic): food sensitivities, headache, chronic urinary tract infection, fatigue, etc… Candidiasis, cont. Diagnosis Controversial: delineation between colonization and infestation is arbitrary • Acute cases: skin biopsy • Chronic cases: stool samples (expensive, time consuming) Treatment: Topical anti-fungals for skin problems Internal anti-fungals for chronic problems • Reestablish balance between bacteria/yeasts (acidophilus) Candidiasis, cont. Massage? For severe problems, get information on underlying problems (immune weakness, etc.) For chronic problems, massage may be safe and appropriate Pancreatitis Inflammation of the pancreas Can be acute or chronic Incidence 50,000–80,000 diagnoses of acute pancreatitis/year Unknown statistics for chronic pancreatitis; mostly related to alcoholism Pancreatitis, cont. Pancreatitis occurs when the pancreatic duct is blocked and the secretions damage the organ Acute pancreatitis: • blunt trauma, gallstones, cystic fibrosis, exposure to alcohol or other toxins: sudden onset, medical emergency Chronic pancreatitis: • permanent damage to gland; ducts are calcified; usually related to alcohol abuse Pancreatitis, cont. Signs and symptoms: Upper abdominal pain • For acute: extreme, sudden onset • For chronic: may build to a crisis, then resolve until next episode; pain eventually becomes unremitting Loss of pancreatic enzymes, hormones Jaundice if common bile duct is blocked Pancreatitis, cont. Treatment: Depends on cause • Removal of damaged tissue; open blocked ducts; supplement digestive enzymes; sever nerves if necessary Massage? Pancreas can refer pain to the back • Persistent pain in a new pattern should be referred to a primary care provider Acute pancreatitis requires medical attention; chronic pancreatitis that is being treated may be appropriate within client comfort A person with a history of pancreatitis but no current symptoms is a good candidate for massage Peritonitis Infection in the peritoneum Dark, moist, 100°: a perfect growth medium! (Fig. 7.14) How does the infection get started? Rupture of an organ (ulcerative colitis, appendicitis) Abscess (ulcerative colitis, pelvic inflammatory disease) Mechanical perforation (knife wound, etc.) Spontaneous peritonitis (long-standing ascites) Peritoneal dialysis (contaminated equipment) Peritonitis, cont. Signs and symptoms: Diffuse abdominal pain Nausea, vomiting, dehydration Reduced urine output Intestinal paralysis Treatment: Antibiotics, surgery if necessary Massage? This is a medical emergency; massage is systemically contraindicated until all signs of infection have passed Hernia Hole in abdominal muscular wall Etiology: Weakness in muscular wall allows contents to push through Reducible, but may get progressively worse Hernia, cont. Signs and symptoms (types of hernias): Epigastric: split in linea alba; omentum protrudes; not extremely painful (mostly men) Paraumbilical: linea alba splits at umbilicus (mostly women) Femoral: bulge into femoral ring; most common in women; can be dangerous Inguinal: most common, usually in men or infant boys; inguinal ring is stretched and small intestines are trapped (Fig. 2.38) (Hiatal: diaphragmatic hiatus is stretched—see more in gastroesophageal reflux disorder [GERD]) Hernia, cont. Complications: Strangulation, necrosis of small intestine Bigger hernias are safer—lower risk of damage Treatment: Surgery (mesh, not just stitches) Truss (temporary measure) Massage? Presurgical is local contraindication Postsurgical is safe and appropriate (with postoperative cautions) Irritable Bowel Syndrome (IBS) Digestive system dysfunction with no structural changes Also called spastic colon, irritable colon, mucus colitis, functional bowel syndrome Incidence: 20%–30% in the United States have IBS symptoms at some point 5 million doctor visits/year Women > men, 3:1 Irritable Bowel Syndrome (IBS), cont. Hyperreactive muscle tissue in colon Peristalsis becomes uncoordinated Dysfunction in ―brain–gut axis‖: feedback loop between sensory and motor neurons that control bowel function Other smooth muscle anomalies: • Neurally mediated hypotension: seen with chronic fatigue syndrome • Well-established overlap between CFS, IBS, and fibromyalgia Closely associated with emotional stress Irritable Bowel Syndrome (IBS), cont. Signs and symptoms: Pain, cramps, gas, bloating, alternating cycles of constipation and diarrhea Diagnosis: Ruling out other conditions Colonoscopy shows no structural changes: only functional problems Irritable Bowel Syndrome (IBS), cont. Treatment: Look for triggers, avoid them Coping strategies for stress Add fiber, bulk to diet Medications to help symptoms, anti-depressants Massage? If the client is comfortable, massage has many benefits, little risk: • Parasympathetic state, more efficient peristalsis, etc. • No structural changes, no risk of infection, perforation, structural damage Ulcerative Colitis Progressive inflammation and ulceration of the colon Part of ―inflammatory bowel disease‖ (IBD) along with Crohn disease Incidence: Approximately 1 million in United States have IBD Evenly split between Crohn disease and ulcerative colitis Men = women Most are 15–25 years old, or 55–65 years old at diagnosis Ulcerative Colitis, cont. Most agree it is autoimmune attack on mucosa of colon Flares and remission Begins in rectum Moves in continuous, connected affected area proximally up the colon (not patchy, like Crohn) Ulcerative Colitis, cont. Signs and symptoms: During flare: • Chronic diarrhea with blood and pus in stool • Cramping, loss of appetite, fever May affect other tissues, systems: • Hepatitis, arthritis, osteoporosis, anemia, uveitis, kidney stones Ulcerative Colitis, cont. Complications: High risk of colorectal cancer Toxic megacolon Treatment: Medications to limit severity Steroidal anti-inflammatories, nicotine patches Surgery to remove affected section of colon Ulcerative Colitis, cont. Massage? Deep abdominal work is contraindicated • Structural problems; colon is vulnerable to entrapment • During remission, massage may help to balance factors to reduce frequency of flares Celiac Disease Villi in small intestine are damaged because of gluten sensitivity Also called celiac sprue, nontropical sprue, glutensensitive enteropathy Incidence: Diagnosed in 1:4,300 May be present (mild forms) in 1:133 Strong genetic link Celiac Disease, cont. Autoimmune or allergic reaction to gluten Gluten breaks down into gliadin; gliadin is absorbed into villi, causing inflammatory response Villi degenerate, limiting access to all nutrients Occurs often with other autoimmune diseases: • Rheumatoid arthritis, type 1 diabetes, thyroid disorders Celiac Disease, cont. Signs and symptoms: Malabsorption of nutrients: • GI pain, bloating, gas, diarrhea • Evidence of nutritional deficiency Symptoms can be severe or subtle Complications: Anemia; folic acid deficiency (birth defects in babies); osteomalacia, osteoporosis; muscle spasms; failure to thrive; risk of seizures, CNS dysfunction with B12 deficiency Chronic irritation can lead to cancer in GI tract; higher risk of non-Hodgkin’s lymphoma Celiac Disease, cont. Diagnosis: Blood test, tissue biopsy Mild cases can resemble… • Irritable bowel syndrome, general indigestion, Crohn disease, ulcerative colitis, chronic fatigue syndrome, depression… Treatment: Avoid gluten in any form • This can be a challenge! Celiac Disease, cont. Massage? Has no impact on the disease, may relieve symptoms temporarily • If client knows s/he has celiac disease, this is appropriate • If client has symptoms without diagnosis, s/he needs to seek medical care—not just massage Crohn Disease Progressive patchy areas of inflammation, all through the GI tract Incidence: Approximately 500,000 in the United States Men = women; average age at onset is 27 years Most common in United States, Canada, Scandinavia Caucasians > other groups, 4:1 Genetic component: increased incidence within families Crohn Disease, cont. Patchy inflamed regions (Fig. 7.2) Often starts at the ileum, can affect anywhere in the GI tract Inflammation can lead to ulcers, perforation, stenosis, fistulae Causes: Most consider it idiopathic • Exposure to paratuberculosis mycobacterium? • Stress, food triggers • High levels of certain cytokines Crohn Disease, cont. Signs and symptoms: Goes in flare and remission • During remission it may be silent • During flare: GI pain, cramping, diarrhea (with blood), bloating, weight loss, fever, joint pain, ulcers in mouth and throat, lesions on skin, anal fissures… Crohn Disease, cont. Complications: In children: impaired growth, delayed development Abscesses, perforations, risk of peritonitis Bowel obstructions Fistulae drain bowel contents into other hollow organs (uterus, bladder) Risk of colon cancer Blocked ducts can lead to cirrhosis, jaundice Lesions on legs, ankles Crohn Disease, cont. Treatment: Steroidal anti-inflammatories, immunosuppressant drugs to limit inflammation Surgery to remove damaged tissue (usually has to be repeated) Early, aggressive course of antibiotics (?) Careful eating (liquid or even IV diet during flare) Massage? Avoid during flares—or energetic work only During remission bodywork may be good coping strategy; improves intestinal function Appendicitis Inflammation, usually with infection, of vermiform appendix (suspended from cecum) Incidence: 1:1,000/year Approximately 7% will eventually have appendicitis Appendicitis, cont. Appendix is a hollow organ with some immune system function When it is blocked, it can develop infection • Abscesses, perforation, rupture may lead to peritonitis Signs and symptoms: Extremely variable • • • • • Food aversion Pain that settles in lower right quadrant Rebound pain Nausea, vomiting, fever Pain on coughing, sneezing, abdominal movement Appendicitis, cont. Complications: Peritonitis Diagnosis: Still difficult; resembles gallstones, pancreatitis, Crohn disease, ulcerative colitis, diverticulitis, pelvic inflammatory disease, ectopic pregnancy… Appendicitis, cont. Treatment: Surgery, open or laparoscopic • Antibiotics are not usually permanently successful Massage? This is an emergency that requires medical attention Postsurgical massage may be appropriate, with respect for pain and the risk of infection Clients with a history of appendectomy are good candidates for massage Diverticular Disease Bulges in the small or large intestine (diverticulosis) that may become infected (diverticulitis) (Fig. 7.7) Incidence: Up to 50% of people 60–80 years of age have diverticula Up to 66% of people over 85 have diverticula Men = women Diverticular Disease, cont. Bulges form during segmentation Mucosa and submucosa herniate through muscularis to form small sacs: diverticula Diverticula may collect fecal matter, bacteria 20% of people with diverticulosis develop diverticulitis: infected diverticula Mostly form in descending, sigmoid colon; can be anywhere in GI tract Diverticular Disease, cont. Signs and symptoms: Diverticulosis may be silent Diverticulitis: pain, nausea, fever, cramping; slow or sudden onset Complications: Bleeding Abscesses Perforation Blockage Fistulae Difficult to accurately screen for colorectal cancer Diverticular Disease, cont. Treatment: For diverticulosis: high-fiber diet, exercise to prevent future sacs from forming For diverticulitis: antibiotics, controlled diet, surgery if necessary Massage? If the client knows s/he has diverticula but no infection, conduct deep abdominal work with special care: the colon is compromised and vulnerable to damage Acute infection (diverticulitis) systemically contraindicates massage Colorectal cancer Development of tumors anywhere in large intestine or rectum Incidence: 135,000 diagnoses/year 56,000 deaths/year Most are >50 years old Close to 6% in United States will eventually have colorectal cancer Colorectal Cancer, cont. Most cases begin with adenomas: polyps somewhere in the bowel (Fig. 7.5) Eventually, oncogenes are activated Tumor-suppressor genes are inhibited Cells replicate, infiltrate deeper layers of the colon (Fig. 7.6) • Metastasize through lymph system to brain, liver, lungs Colorectal Cancer, cont. Causes: 30%–40% of older Americans have polyps; the longer they are present, and the bigger they are, the higher the risk of cancer cells • High-fat foods linger in colon longer, become carcinogenic? • High-fiber diets ―scrub‖ colon, reducing risk of lingering carcinogens? • Phytochemicals suppress malignant changes? Colorectal Cancer, cont. Risk Factors: Obesity Genetics (colon cancer genes raise risk; only 5% of colon cancer patients have these genes) Inflammatory bowel disease (Crohn disease and ulcerative colitis) Age (over 50 years old) Colorectal Cancer, cont. Signs and symptoms: Constipation, narrowed stools, anemia from chronic blood loss Diagnosis: Digital rectal examination, fecal occult blood test, sigmoidoscopy, colonoscopy, CT scan Colorectal Cancer, cont. Treatment: Stage I or II: surgery to resect bowel Stage III or IV: surgery, chemotherapy, radiation Massage? Same guidelines as for all cancer patients: work with health care team to maximize benefits, minimize risks Clients with colostomy bags are good candidates for massage; locally avoid the bag and ask the client how to make him or her comfortable Cirrhosis Healthy liver cells are replaced with scar tissue Usually a result of some other disorder Incidence: Liver disease affects 25 million in the United States 25,000–35,000 deaths/year #8 cause of death in the United States Cirrhosis, cont. Hepatocytes are highly organized, delicate cells Chronic irritation (viral attack, toxic exposures) causes hepatocytes to die off, replaced with scar tissue (Fig. 7.8) Channels are blocked; liver function is decreased Bumpy appearance: ―hobnailed liver‖ Cirrhosis, cont. Causes: Alcoholism, hepatitis C are major causes • Others include other forms of hepatitis, gallstones, environmental toxins, heart failure Signs and symptoms: Subtle in early stages (liver can compensate for lost function): • Nausea, vomiting, weight loss, red patches on skin In later stages complications develop Cirrhosis, cont. Complications: Portal hypertension (back-up of fluid in portal system), leads to… • Splenomegaly, ascites (Fig. 7.9), internal varices Bleeding, bruising (lack of clotting factors) Muscle wasting Jaundice Systemic edema Hormone disruption Encephalopathy Kidney failure Cirrhosis, cont. Treatment: Stop the damage! Manage complications Transplant, if necessary • 12,000 on waiting list; 5,300 performed/year Massage? Liver is a keystone for fluid management; advanced cirrhosis contraindicates circulatory massage Get information about possible complications and cautions for bodywork Noncirculatory massage may be safe and appropriate Gallstones Formation of stones in gallbladder Also called cholelithiasis Incidence: 20 million in the United States have been diagnosed with gallstones 1%–3% have symptoms/year Women > men, 2:1 Gallstones, cont. The gallbladder stores and concentrates bile, releases it into small intestine for emulsification of fats When cholesterol or other substances accumulate in high concentration, tiny crystals (bile sludge) or larger stones may form Gallstones, cont. Contributing factors: Obesity Estrogen Race, gender, age Cholesterol-lowering drugs Diabetes Rapid weight loss Fasting Gallstones, cont. Signs and symptoms: 80% are completely silent Symptoms occur when stone is in duct (Figs. 7.10, 7.11) • Pain at right costal angle, refers between scapulae, right shoulder Complications: If a stone gets lodged, the duct is blocked • Jaundice, cirrhosis • Pancreatitis Infection of gallbladder • Possible rupture and peritonitis Gallstones, cont. Treatment: Surgery to remove gallbladder • Usually laparoscopic New procedures try to preserve gallbladder Postsurgery, may have difficulty digesting fats Massage? Acute biliary colic requires medical attention, not massage • Refers to scapulae, right shoulder Clients with a history of gallstones or gallbladder surgery and no present symptoms are fine for massage • If the client knows gallstones are present, avoid the right costal angle Hepatitis Viral attack on the liver Until late 70s: hepatitis A, hepatitis B, hepatitis non-A non-B Now we have identified hepatitis A, B, C, D, E, F, G 90% of infections are A, B, or C Exposure to one gives no protection from others Hepatitis, cont. Signs and symptoms: Severity and duration of symptoms depends on type of infection • • • • Malaise Nausea Fatigue Jaundice Hepatitis A Incidence: 180,000 infections/year, 30% adults test positive for exposure Pattern: Most acute, shortest lasting (only by comparison; it still lasts several weeks) 1 infection imparts immunity Hepatitis A, cont. Communicability: Spread through oral–fecal contamination • Water, shellfish, food workers Also communicable through shared fluids • Needles, sexual activity Treatment: Rest, supportive therapy Gamma globulin shot (―borrowed‖ antibodies) Vaccine is available Hepatitis B Incidence: 200,000 new infections/year; mostly among newly sexually active teens and young adults 1–1.25 million are chronic carriers Pattern: Less acute, but longer lasting (many months or years) 5% become chronic carriers • High risk of liver disease: cirrhosis, liver failure, liver cancer Hepatitis B, cont. Communicability: Highly communicable in shared fluids—viral load is high so minimal contact is needed. • Very sturdy outside a host: 6 months at room temperature • Tattoo needles, acupuncture needles, drug needles, sexual activity, long-term close contact Treatment: Antiviral medication Vaccine is available: required for some health care professions Hepatitis C Incidence: Currently carried by 4 million in United States 3 million have it as a chronic infection Most people were infected 1–3 decades ago Causes 8–10,000 deaths/year Pattern: Symptoms don’t appear for many years after infection 25% spontaneously recover; 75% have a high risk of liver disease Rivals alcoholism for leading cause of cirrhosis #1 reason for liver transplants Hepatitis C, cont. Communicability: Shared fluids Treatment: Antivirals (the sooner the better) No vaccine is available Hepatitis, general Massage for any type of hepatitis? Fluid management problems contraindicate circulatory massage • Chronic hepatitis B or C may be safe, depending on health and resilience of the client—compare massage to activities of daily living Energetic or reflexive techniques may be safe and appropriate Get information about complications Clients who have fully recovered from hepatitis infection are good candidates for massage Jaundice Symptom of liver dysfunction Bilirubin (by-product of RBC dismantling in the spleen) is an ingredient of bile When the liver does not drain correctly (obstructed channels, ducts), bilirubin accumulates in the bloodstream, leading to discoloration of skin, eyes, mucous membranes Jaundice, cont. Types of jaundice: Neonatal jaundice: • Immature liver, spleen; treated with exposure to ―bililights‖ to stimulate liver activity Hemolytic jaundice: • Related to hemolytic anemia: premature death of RBCs Hepatic jaundice: • Any problem that originates in the liver: cirrhosis, hepatitis, etc. Extrahepatic jaundice: • Any obstruction of ducts that originates outside the liver: gallstones, tumors, pregnancy Jaundice, cont. Signs and symptoms: Accumulation of bilirubin in skin, mucous membranes: • Eyes, gums, skin become yellowish (Fig. 7.12) • Urine is dark • Feces are pale (bilirubin in urinary system, not digestive tract) Jaundice, cont. Complications: Poor secretion of bile means less access to fatsoluble vitamins, especially vitamin K (related to bleeding disorders) Massage? Depends on what causes the jaundice, what kind of care the client is getting, and the ability to manage fluid movement in the body • Generally this is an indication of a primary problem that contraindicates circulatory massage • It may indicate a potentially communicable infection • Work with health care team for best benefit, least risk Liver Cancer Malignant cells that originate in the liver Also called hepatocellular carcinoma Not metastatic liver disease (metastasis from another location) Incidence: Worldwide fairly common United States: 15,000 diagnoses/year, 15,000 deaths Statistics expected to rise with maturation of hepatitis C patients Men > women, 4:1 among some groups Liver Cancer, cont. Hepatocytes replicate out of control Related to history of cirrhosis, hepatitis, alcoholism May form single or multiple tumors • Highly invested with blood vessels: high risk of metastasis Liver Cancer, cont. Risk factors: HBV, HCV infection Alcoholism Hemochromatosis Cirrhosis Aflatoxin B1 (toxin common in Asia, SubSaharan Africa) Liver Cancer, cont. Signs and symptoms: Similar to signs of hepatitis, cirrhosis, which are probably also present: • Nausea, food aversion, weight loss, ascites, muscle wasting, fever, jaundice Diagnosis: CT scan, ultrasound, MRI, biopsy • Important to distinguish between liver cancer and metastatic liver disease Liver Cancer, cont. Staging: Described by treatment option rather than progression: • Resectable vs. unresectable Treatment: Often not responsive to chemotherapy, radiation Many patients not good candidates for open surgery Closed surgery options in development 5-year survival rate <10% Liver Cancer, cont. Massage? As with other cancers, work with health care team for best benefit, minimum risk May improve tolerance of treatment Comfort measure for dying person Pancreatic Cancer Uncontrolled replication of pancreas cells Usually in exocrine ducts Sometimes in endocrine-producing cells Incidence: 30,000 diagnoses/year 30,000 deaths/year Life expectancy: 4–6 months post-diagnosis Pancreatic Cancer, cont. Two types of pancreatic cancer: Adenocarcinoma (tumor in exocrine ducts) Neuroendocrine tumors (occur in islet cells) Metastasis: • Through direct contact with other abdominal structures • Through lymphatics to the liver Pancreatic Cancer, cont. Risk factors: Age, gender, race Smoking Chronic pancreatitis Diabetes Diet Colon cancer, breast cancer genes History of melanoma Pancreatic Cancer, cont. Signs and symptoms: Usually too subtle to notice in early stages • Weight loss, abdominal discomfort, loss of appetite • Jaundice, ascites, other liver signs if duct is blocked • Blood glucose disruption if islet cells are affected Diagnosis: Difficult to get accurate diagnosis without risk of spreading cancer cells Pancreatic Cancer, cont. Staging • Potentially resectable • Locally advanced • Metastatic Treatment: Surgery when possible, radiation, chemotherapy • May prolong life by several months; not usually curative • Surgery may be performed to correct blockages Pancreatic Cancer, cont. Massage? As with other types of cancer, work with health care team for best benefit, minimum risk May improve tolerance of treatment Appropriate as comfort measure for dying person