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					               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 immune-
      suppressed 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, gluten-
   sensitive 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 ―bili-
      lights‖ 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 fat-
   soluble 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, Sub-
   Saharan 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

				
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