Gastrointestinal Disorders

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1 & Bartlett Lear R S CHAPTER 5 Gastrointestinal Disorders Bartlett Lear Gastroesophageal Reflux Disease Hiatal Hernia Irritable Bowel Syndrome Constipation Diarrhe Colorectal Cancer & Bartlett L R SALE OR & Bartlett Lear R SALE OR DISTRIBUTIO & Bartlett Lear R S Bartlett Lear & Bartlett L R SALE OR D & Bartlett Lear R SALE OR DISTRIBUTIO & Bartlett Lear R S tofutyklein/shutterstock 105 & Bartlett Lear. R S

2 & Bartlett Lear R S Bartlett Learning, Gastroesophageal LLC Reflux Disease & Bartlett L Gastroesophageal reflux disease (GERD), also known as acid reflux, R SALE OR is a chronic condition of the lower esophagus and stomach that occurs when contents of the stomach reflux back into the esophagus. Epidemiology Approximately 14% of all adult women suffer from GERD. Etiology Control of the transport of food from the esophagus to the stomach is regulated by the lower esophageal sphincter. Inadequate functioning of the sphincter allows the stomach s acidic contents to regurgitate back into the esophagus. Causes of lower esophageal & Bartlett Lear R S & Bartlett Lear R SALE OR DISTRIBUTIO sphincter anomalies include hiatal hernias and general sphincter weakening, sometimes as a result of smoking. Other causes of GERD include the following: Pregnancy Diet Obesity Chronic, persistent cough Excessive physical exertion Iatrogenic causes (e.g., heartburn is a side effect of some medications) Bartlett Lear & Bartlett L R SALE OR D TECHNICAL NOTE & Bartlett Lear R SALE OR DISTRIBUTIO Current understanding implicates Helicobacter pylori infection as a cause of GERD. H. pylori can cause low-grade inflammation and lead to ulcers in the stomach. CLINICAL PEARL & Bartlett Lear R S Some anecdotal evidence supports the proposed theory that GERD is in part caused by the stomach producing too little acid. 106 & Bartlett Lear. R S

3 & Bartlett Lear R S Bartlett Learning, Signs and Symptoms LLC Acid indigestion Burning pain in the chest Pain in the neck Pain in the throat & Bartlett L R SALE OR Diagnoses & Bartlett Lear Esophageal ph monitoring to measure the quantity of acid in the esophagus over a 24- NOT to 48-hour FOR period SALE OR DISTRIBUTIO Endoscopy if symptoms are moderate or severe to examine for esophagitis, esophageal strictures, and Barret s esophagus Manometry to assess the function of the lower esophageal sphincter and the need for surgery & Bartlett Lear R TECHNICAL SALE OR NOTE DIS Conventional and alternative medicine sources differ dramatically in the understanding of and approach to managing GERD. Whereas the conventional medicine literature espouses high acid levels as the cause of GERD, alternative medicine sources espouse abnormal gut health as a result of the wrong balance of the gut flora as a primary cause of GERD. Bartlett Lear Management Conventional Medications H2 blockers to decrease stomach acid, including the following: Cimetidine (Tagamet) Famotidine (Pepcid) Ranitidine (Zantac) CLINICAL PEARL & Bartlett L R SALE OR D & Bartlett Lear R SALE OR DISTRIBUTIO Research evidence suggests that suppression of stomach acid, although helpful for symptomatology, does not address the underlying causes of GERD. & Bartlett Lear R S 107 & Bartlett Lear. R S

4 & Bartlett Lear R S Bartlett Learning, CLINICAL PEARL LLC Proton pump inhibitors are recommended primarily for severe GERD with bleeding ulcers. & Bartlett L R SALE OR Complementary Acupuncture & Bartlett Lear Some studies suggest that acupuncture R may SALE provide OR some DISTRIBUTIO benefit for GERD. Nutraceuticals Small-scale studies and anecdotal reports suggest that the following may decrease symptoms of GERD: Probiotics Melatonin & Bartlett Lear R S Self-Care and Wellness Conventional Approaches Bartlett Learning, Eating smaller LLCmeal portions & Bartlett L Avoiding known triggers, including cigarette NOT smoke, FOR some SALE OR D citrus fruits, alcohol, fatty foods, and tomatoes Eating a few hours before bedtime Managing weight Sleeping with the head and upper back elevated Complementary and Alternative Approaches & Bartlett Lear Eating whole foods R SALE OR DISTRIBUTIO Eating unprocessed foods Enhancing gut health via the following: Fermented vegetables Cultured dairy products, including yogurt, sour cream, & Bartlett and kefir Lear R S 108 & Bartlett Lear. R S

5 & Bartlett Lear R S Fish, such as mackerel Himalayan (and other) sea salts with high chloride content to increase the production of hydrochloric acid Gut stimulants, such as cabbage Bartlett Lear Hiatal Hernia Hiatal hernias occur when parts of the stomach herniate through the diaphragm. Epidemiology The incidence of hiatal hernia is thought to be significantly underreported; however, estimates are similar to those for GERD. Approximately 14% of all women and 40% of obese women have some form of hiatal hernia. Etiology The cause is unknown but may include anything that places pressure on the diaphragm and surrounding tissue, such as pregnancy, persistent coughing or straining, and obesity. In addition, laxity associated with age may cause a predisposition to hiatal hernias. Signs and Symptoms Sometimes none Heartburn Chest pain Belching/burping Difficulty swallowing & Bartlett Lear R S Bartlett Lear Excessive feelings of fullness following a meal & Bartlett L R SALE OR & Bartlett Lear R SALE OR DISTRIBUTIO Diagnosis Blood analysis (complete blood count [CBC]) to rule out anemia Barium swallow to visualize the stomach, esophagus, and duodenum on x-ray & Bartlett Lear R S & Bartlett L R SALE OR D & Bartlett Lear R SALE OR DISTRIBUTIO 109 & Bartlett Lear. R S

6 & Bartlett Lear R S Endoscopy to check for inflammation Manometry to assess function of the lower esophageal sphincter and assess for the need for surgery Bartlett Lear & Bartlett L R SALE OR Management Medications Antacids, such as Maalox, Tums, Jones and & Rolaids Bartlett Lear H2 receptor blockers, such as cimetidine (Tagamet) and R SALE OR DISTRIBUTIO famotidine (Pepcid AC), to decrease acid production Proton pump inhibitors, such as omeprazole (Prilosec OTC), to block acid production and heal the esophagus Surgery is rarely performed in severe cases. & Bartlett Lear R Complementary S The hiatal hernia maneuver, as performed by many chiropractors (see the Appendix) Self-Care and Wellness Bartlett Learning, Eat smaller LLC meals. & Bartlett L Minimize heavy lifting, straining, and bending NOT over. FOR SALE OR D Improve seated and standing posture; avoid slouching. Sleep on an incline, with the head of the bed raised 4 to 6 inches on blocks. Choose activities that involve standing rather than sitting or reclining. Avoid meals within 2 hours of bedtime. & Bartlett Lear The following exercise is NOT anecdotally FOR reported SALE to provide OR some DISTRIBUTIO patients with relief: After drinking a small glass of warm water, stand on the toes, and then drop down to the heels, with the arms above the head. The exercise is repeated 10 times every morning on arising. & Bartlett Lear R S 110 & Bartlett Lear. R S

7 & Bartlett Lear R S Bartlett Learning, TECHNICAL LLC NOTE Hiatal hernias may be classified as follows: Type 1 Sliding Hiatal Hernia (Concentric/Axial) Accounts for 95% of all hiatal hernias Correlated with GERD Type 2 Paraesophageal hernia Gastric fundus herniates Accounts for 5% of all hiatal hernias Type 3 Combination of type 1 Rare and type 2 Type 4 Herniation of other abdominal organs, such as the spleen or colon Very rare R S Irritable Bowel Syndrome Irritable bowel syndrome (IBS) is a disorder of the large intestine. It is characterized by changes in stool frequency, abdominal pain, Bartlett Learning, cramping, and LLC bloating or distension. Although IBS is considered a chronic condition, epidemiologic data suggest that symptoms may subside over time. Epidemiology Reported IBS symptoms are two to three times higher in women than in men. Globally, the prevalence of IBS is 67% higher in women than in men. Of patients who report with IBS, 50% are under 35 years of age; prevalence is 25% lower in people over age 50. Less than half of patients with IBS seek medical attention. Etiology Unknown Food allergies/sensitivities Fluctuating hormones & Bartlett Lear & Bartlett Lear R S & Bartlett L R SALE OR & Bartlett Lear R SALE OR DISTRIBUTIO & Bartlett L R SALE OR D & Bartlett Lear R SALE OR DISTRIBUTIO 111 & Bartlett Lear. R S

8 & Bartlett Lear R S Stress Prior illness of the gut Bartlett Lear Signs and Symptoms Abdominal pain relieved by defecation Frequent stools Constipation Altered stool frequency Bloating Passing mucus during a bowel movement Symptoms for more than 6 months & Bartlett L R SALE OR & Bartlett Lear R SALE OR DISTRIBUTIO Diagnosis & Symptoms Bartlett (see Learning, Table 5-1) LLC Sigmoidoscopy R S Colonoscopy Imaging of the abdomen, including x-rays, computed tomography (CT) scans, and barium studies Blood tests to rule out other diseases, such as celiac disease Assessment for lactose intolerance Bartlett Learning, Stool analysis LLC Management Conventional Medications Antidiarrheals, such as loperamide (Imodium) Antispasmodics, such as dicyclomine (Bentyl) Antibiotics, such as rifaximin (Xifaxan) Antidepressants, including the tricyclics, such as Amitriptyline (Elavil); the selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac); and the serotonin norepinephrine reuptake inhibitors (SNRIs), such as duloxetine (Cymbalta) Fiber supplements, including psyllium (e.g., Metamucil) Medications to relax the colon, such as alosetron (Lotronex) Other symptom-specific medications & Bartlett Lear R S & Bartlett L R SALE OR D & Bartlett Lear R SALE OR DISTRIBUTIO 112 & Bartlett Lear. R S

9 & Bartlett Lear R S Table 5-1 Manning Criteria Two or More Symptoms Suggest IBS Bartlett Lear Onset of pain linked to more frequent bowel movements Looser stools associated with onset of pain Pain relieved by passage of stool Noticeable abdominal bloating Sensation of incomplete evacuation more than 25% of the time Diarrhea with mucus more than 25% of the time Source: Manning, A.P., Thompson, W.G., Heaton, K.W., Morris, A.F. (1978). Towards positive diagnosis of the irritable bowel. British Medical Journal, 2(6138): & Bartlett L R SALE OR & Bartlett Lear R SALE OR DISTRIBUTIO Complementary & Acupuncture: Bartlett Learning, Several research LLC studies suggest that acupuncture is a valuable therapy for relieving the symptoms of IBS. R Therapies SALE OR aimed DIS at regulating the nervous system: Therapies such as Logan Basic and spinal touch (see the Appendix) are anecdotally reported to relieve the symptoms of IBS Herbs: Numerous herbs have been identified in multiple studies as improving some of the symptoms of IBS. They include Bartlett Learning, the following: LLC Single herbs: Essential oil of Mentha piperita Cynara scolymus Curcuma longa extract Maranta arundinacea Herbal preparations: Carmint STW 5 Padma Lax & Bartlett L R SALE OR D & Bartlett Lear R SALE OR DISTRIBUTIO Self-Care and Wellness Diet & Remove Bartlett lactose-containing Learning, foods LLCfrom the diet if lactose R intolerance SALE OR is contributing DIS to the symptoms. 113 & Bartlett Lear. R S

10 & Bartlett Lear R S Remove gluten-containing foods from the diet if gluten sensitivity or celiac disease is contributing to the symptoms. Bartlett Lear & Bartlett L Complete a food diary to assess for other NOT foods that FOR may SALE OR aggravate symptoms. Try food-elimination diets to assess for other foods that may aggravate symptoms. Eat at regular intervals. Ensure adequate hydration. & Bartlett Lear Exercise regularly. R SALE OR DISTRIBUTIO Constipation Constipation is a condition in which there is difficulty emptying the bowel, usually associated with hardened feces. & Bartlett Lear Epidemiology R S Depending on the definition of constipation, prevalence rates range from 2% to 28%. Constipation is twice as common in women as in men. Etiology Bartlett Lear & Bartlett L Inadequate dietary fiber Perceived and real difficulties in defecation, including R limited SALE OR D urge to defecate Impaired colonic motor activity Dysfunction of the pelvic floor Dysfunction of the anal sphincter Medications, including antacids, Jones psychoactive & Bartlett medications, Lear opioids, and numerous others, that impair defecation R SALE OR DISTRIBUTIO Endocrine and metabolic disorders, such as hypothyroidism, parathyroidism, and diabetes Pregnancy Gastrointestinal conditions, such as Crohn s Neurologic conditions, including multiple sclerosis and & Parkinson s Bartlett Lear R Structural SALE OR abnormalities DIS 114 & Bartlett Lear. R S

11 & Bartlett Lear R S Bartlett Learning, Signs and Symptoms LLC & Bartlett L Lumpy or hard stools R SALE OR Less than three bowel movements every week The need to manually remove stools Significant straining to have bowel movements Incomplete emptying of stools Diagnosis & Bartlett Lear Colonoscopy R SALE OR DISTRIBUTIO Sigmoidoscopy Colonic transit studies Defecography (x-ray study of the rectum during defecation) Anorectal manometry (evaluation of the anal sphincter) & Bartlett Lear Management R S Conventional Fiber and bulking agents to increase stool weight, such as psyllium, polycarbophils, and methylcellulose Laxatives Bartlett Learning, Saline laxatives, LLC including mineral oil, glycerin, and docusate (oral or rectal) & Bartlett L R SALE OR D Osmotics, such as magnesium citrate and MiraLax (polyethylene glycol 3350) Stimulants, such as cascara, used with caution Motility agents, such as Tegaserod (Zelnorm) Physical therapy pelvic floor training and biofeedback Surgery in severe cases & Bartlett Lear R SALE OR DISTRIBUTIO Complementary Spinal manipulation: Multiple studies using chiropractic adjustments delivered through various chiropractic technique systems (e.g., activator, diversified, Thompson, Gonstead) & Bartlett Lear R S suggest improved symptoms in patients with constipation and other gastrointestinal (GI) symptoms. 115 & Bartlett Lear. R S

12 & Bartlett Lear R S Acupuncture: Multiple studies using acupuncture and electroacupuncture suggest improved symptoms following treatment in patients with constipation. Bartlett Lear & Bartlett L R SALE OR Self-Care and Wellness Increasing fiber and water intake Engaging in daily exercise & Bartlett Lear Paying attention to the urge R SALE OR DISTRIBUTIO Diarrhea Diarrhea is the passing of three or more loose stools per day or more frequent passage of stools than is normal for the individual. & Bartlett Lear Epidemiology R S The epidemiology of diarrhea in women remains unclear; estimates are that approximately 9% of the general population has some experience with diarrhea. Diarrhea is an identified manifestation of IBS, a condition that predominates. Bartlett Learning, Etiology LLC Infection in the intestinal tract Contaminated water sources Poor personal hygiene Food prepared or stored in unhygienic conditions IBS Stress Family violence Antibiotics Hormones Estrogen, progesterone, docosahexaenoic acid (DHEA), and cortisol have all been implicated in either slowing or increasing gut transit time. & Bartlett Lear R S & Bartlett L R SALE OR D & Bartlett Lear R SALE OR DISTRIBUTIO 116 & Bartlett Lear. R S

13 & Bartlett Lear R S Bartlett Learning, Signs and Symptoms LLC Loose, watery, frequent stools Signs of dehydration Abdominal pain Diagnosis History and exam (including blood pressure to assess for dehydration; abdominal examination) Jones & Bartlett Lear Review of medications R SALE OR DISTRIBUTIO Stool testing for mucus, blood, and pathogens Laboratory analysis for dehydration, altered blood chemistries, and antibody tests for parasites or celiac disease Management & Bartlett Lear R Conventional S Rehydration (water, salt, sugar/juices) Zinc supplements (may reduce the duration of diarrhea by as much 25%) Nutrient-rich foods Bartlett Learning, Medication LLC adjustment Intravenous rehydration if necessary Complementary Assessment for and removal of all food allergens Probiotics Green tea Pomegranate extract & Bartlett L R SALE OR Self-Care and Wellness Avoid caffeine and alcohol. Avoid foods with high sensitivity risk, including dairy products and spicy foods. Practice good hygiene habits. & Bartlett Lear R S Other management strategies include those described earlier for IBS. 117 & Bartlett Lear. R S & Bartlett L R SALE OR D & Bartlett Lear R SALE OR DISTRIBUTIO

14 & Bartlett Lear R S Bartlett Learning, CLINICAL PEARL LLC The most severe threat posed by diarrhea is dehydration. & Bartlett L R SALE OR CLINICAL PEARL According to the World Health Organization (2013) diarrheal disease is the second leading cause of death in children under 5 years old and is responsible for the deaths of 760,000 children every year. & Bartlett Lear R SALE OR DISTRIBUTIO Colorectal Cancer Colorectal cancer is cancer of the large intestine and rectum. Epidemiology & Bartlett Lear R Colorectal SALE cancer OR is DIS the second most common cancer in U.S. women of Hispanic, American Indian/Alaska Native or Asian/ Pacific Islander descent and the third most common cancer in U.S. Caucasian and African American women. It is most commonly diagnosed in women after age 50. Bartlett Lear & Bartlett L CLINICAL PEARL R SALE OR D Deaths from colorectal cancer rank third, after lung and breast cancer, for women. Etiology Unknown & Bartlett Lear Gene mutations and other NOT hereditary FOR factors SALE OR DISTRIBUTIO Diet Diets that are high in fat and low in fiber have been associated with colorectal cancer. Signs and Symptoms & Bartlett Lear Rectal bleeding R Rectal SALE pain OR DIS 118 & Bartlett Lear. R S

15 & Bartlett Lear R S Table 5-2 Staging for Colorectal Cancer Stage Cancer Distribution 1 Involves the mucosa of the colon and rectum 2 Involves the colon and rectum; doesn t involve lymph nodes 3 Involves local lymph nodes 4 Involves distal sites Bartlett Lear & Bartlett L R SALE OR & Bartlett Lear Altered bowel patterns that NOT persist FOR SALE OR DISTRIBUTIO Abdominal bloating Abdominal pain Signs of anemia, including fatigue and generalized pallor Weight loss & Bartlett Lear R Diagnosis S History and exam Colonoscopy Blood analysis for carcinoembryonic antigen Abdominal CT scans Bartlett Lear & Bartlett L Management R SALE OR D Conventional Conventional management is dependent on staging (see Table 5-2) and might include the following: Surgery Chemotherapy & Bartlett Lear Radiation therapy R SALE OR DISTRIBUTIO Self-Care and Wellness Exercise as recommended by the National Cancer Institute (NCI, 2010), thirty minutes a day for most days of the week; avoiding exercises that increase intra-abdominal pressure & Bartlett Lear Diet that is low in red and processed meat R High-fiber SALE OR foods, DIS such as split peas, lentils, and black beans Colonoscopy every 5 years after age & Bartlett Lear. R S

16 & Bartlett Lear R S Bartlett Lear & Bartlett L R SALE OR & Bartlett Lear R SALE OR DISTRIBUTIO & Bartlett Lear R S Bartlett Lear & Bartlett L R SALE OR D & Bartlett Lear R SALE OR DISTRIBUTIO & Bartlett Lear R S & Bartlett Lear. R S

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