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1 SESI 9a GANGGUAN SISTEM PENCERNAAN Disusun oleh dr. Mayang Anggraini Naga U-IEU (Revisi 2014)

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1 1 SESI 9a GANGGUAN SISTEM PENCERNAAN Disusun oleh dr. Mayang Anggraini Naga U-IEU (Revisi 2014)

2 2 DESKRIPSI Pembahasan materi meliput gangguan pada sistem gastro-intestinal, pankreas, hati dan sistem empedu, berserta gangguan diare

3 3 KOMPETENSI Mampu memahami tanda-tanda gangguan sistem gastro-intestinal, pankreas, hati dan sistem empedu, gangguan diare, dan cara pemeriksaannya, implikasi bagi fisioterapi.

4 4 POKOK BAHASAN Menjelaskan: - Gangguan mulut, esofagus - Gangguan lambung dan usus - Gangguan hati, pankreas dan sistem empedu - Penyebab diare dan konstipasi

5 5 GANGGUAN SISTEM PENCERNAAN MULUT: Bagian sistem organ pencernaan yang bertugas: -menghancurkan makanan untuk bisa ditelan (mekanik) -mengubah vibrasi dari pita suara (laring) menjadi speech (bicara) dan -bagian dari saluran pernapasan

6 Mulut (Lanjutan-1) Atap mulut: - palatum durum (bagian keras bertulang) di bagian depan - palatum molle (bagian yang tak bertulang) Pada dasar mulut: - ada lidah yang mengandung sel-sel khusus yang sensitif terhadap cita rasa = taste buds. 6

7 7 Mulut (Lanjutan-2) Sekeliling palatum dan lidah ada gigi yang tertanam di gingiva. Struktur otot dinding mulut membentuk pipi dan bibir. Lapisan membrane mukosa dalam mulut menghasilkan pelumat saliva yang dihasilkan oleh tiga kelenjar ludah.

8 8 GANGGUAN MULUT Mal-ocllusion = hubungan kurang normal, saat mulut tertutup, antara gigi atas dan bawah. Hanya malocllusion yang parah perlu terapi. Ada tiga tipe: Tipe 1 (tipe terumum) = rahang normal, namun gigi tidak tersebar sempurna, terdorong ke atas, rotasi, sehingga rahang atas dan bawah tidak tertemu sempurna

9 9 Malocllusion (Lanjutan-1) Tipe 2 (retrognathism) = pada ini rahang bawah terlalu terdorong ke belakang, gigi incisors jauh ke depan, dan molar jauh ke belakang. Tipe 3 (paling jarang) disebut: prognathism. Rahang bawah terlalu terdorong ke depan, incisors ke dalam dan molar jauh ke depan.

10 10 GANGGUAN MULUT (Lanjutan-2) Gangguan terjadi sejak kanak-kanak, saat pertumbuhan rahang. Sebagian besar adalah genetik, yang lain bisa akibat: -kebiasaan sampai besar menghisap jari, atau adanya -ukuran gigi yang tertalu besar untuk mulut yang kecil, sehingga terlalu berhimpit di rahang.

11 GANGGUAN MULUT (Lanjutan-3) Terapi: Orthodontik (orhtodontic appliance braces), Operasi orthognatic Operasi sebaiknya pada masa masih kanak-2 agar lebih efisien dan efektif. 11

12 12 GANGGUAN ESOFAGUS Berbagai gangguan esofagus seringnya menimbulkan gejala klinis yang sama: -sulit menelan (dysphagia = disfagi) atau -rasa nyeri di belakang dada (nyeri ulu hati) atau -kedua-duanya timbul bersama. Kadang ada laserasi dan varises yang dapat menimbulkan perdarahan.

13 13 Bentuk gangguan esofagus: Atresia (tanpa lubang)  menimbulkan fistula antara esofagus dengan saluran pernapasan. Gangguan juga bisa berupa stenosis (penyempitan lumen) bisa sekunder akibat -fibrosis post inflamasi; -neoplasm; -kolagenisasi dinding esofagus (sklero-derma sistemik; -penekanan dari luar. Terapi: dilatasi dengan busi.

14 14 DIVERTICULI Penonjolan dari dinding dengan ukuran 2-4 cm. Bisa pada: -batas laringo-esofagus; -daerah percabangan trakea; dan -bisa tepat di atas diafragma (> pada gangguan motorik). Causa: peningkatan tekanan intra-lumen

15 (Lanjutan) Keluhan: -bisa tanpa gejala, - bisa disfagia (gangguan perjalanan makanan), -kalau makanan terjebak:  -inflamasi, -ulserasi, -perforasi. 15

16 16 Gangguan Esopfagus (Lanjutan-1) Anulus dan Jerat (web): Ada struktur mirip cincin konsentris yang menjerat esofagus = anulus Schatzki (radiolog) Gejala anulus dan jerat: -disfagi, kadang disertai -glositis, -anemia defisiensi Fe (> wanita manula) Triad disebut: Plummer-Vinson (Patterson- Brown-kelly)

17 17 AKHALASIA (Mega-esofagus) Disfagi akibat gangguan motilitas esofagus karena 3 (tiga) sebab: (1) peristaltik yang tak adekuat pada 2/3 bagian bawah. (2)relaksasi yang tidak adekuat dari otot spinter esofagus bagian bawah. (3) meningkatnya otot sphincter saat istirahat

18 18 Kelainan Akhalasia untuk waktu lama Mega-esofagus. Causa: gangguan saraf dan hormonal. Gejala: disfagia didahului stres emosional  berulang-ulang sakit di belakang sternum (tulang dada),  regurgitasi bila berbaring  iritasi kronik  Ca. AKHALASIA (Mega-esofagus) (Lanjutan)

19 19 HERNIA HIATUS & ESOFAGITIS Hernia ke atas dari lambung melalui pintu hernia hiatus esofagus. Ada 2 macam: 1.Hernia meluncur (sliding); sulit ditegakkan secara Rongent, endoskopik atau histologik. Kelainan minimum, tidak terus menerus, rasa panas epigastrium akibat reflux.

20 (Lanjutan) 2.Hernia menggelinding (rolling) = paraesofagus  menimbulkan: -rasa tidak enak dan penuh di epigastrium post cibum. Jarang menimbulkan keadaan darurat. 20

21 21 ESOFAGITIS Radang esofagus: -bisa akut -bisa kronik, lebih banyak ditemukan pada otopsi. Kadang bersamaan dengan kanker esofagus. Perlu perhatian karena disfagi serta peradangan kronik fibrosis penyempitan, dan predisposisi ke Ca.

22 22 ESOFAGISTIS (Lanjutan) Causa: - alkoholis, - perokok berat, - terpajan bahan korosif, - intubasi lambung untuk waktu lama, - candidiasis, - herpes, - obat-obatan (KCL, antibiotika kemoterapeutik), - uremia, - pemfigus (penyakit kulit, blister besar), - epidermolisis bulosa.

23 23 VARICES ESOFAGUS Sering terjadi perdarahan masif akut. Causa: -ulkus peptikum, -gastritis erosiva, -varises esofagus, -laserasi esofagus.

24 (Lanjutan) Gejala: berlangsung tak bergejala  ruptur (mendadak terjadi perdarahan hebat tanpa rasa sakit). Angka kematian lebih tinggi dari perforasi ulkus peptikum. Perdarahan baru  fatal pada 6-8 minggu post serangan pertama. 24

25 25 LASERASI ESOFAGUS & Ca Laserasi Esofagus (Sindrom Mallory-Weiss) 5-15% dari seluruh perdarahan massif saluran cerna bagian atas. Kanker Esofagus 2% kematian akibat keganasan. Diduga ada hubungan dengan faktor lingkungan.

26 (Lanjutan) Faktor-2 predisposisi: -alkohol, -rokok, -akhalasia, -divertikulum, -esofagitis kronik (leukoplakia dan displasia), -refluks. 26

27 27 LAMBUNG (STOMACH, GASTER) Makanan masuk lambung dari esofagus dan keluar ke dalam duodenum. Selaput lendir lambung mengeluarkan -gastric juice (asam lambung HCL) dan -mukus sebagai pelindung.

28 (Lanjutan) Bagian fundus lambung ialah lanjutan dari esofagus, sedangkan bagian antrum menuju ke duodenum. Masuk/keluar makanan dikontrol oleh: -esophageal sphincters dan -pyloric sphincter. 28

29 29 GANGGUAN LAMBUNG Gangguan bisa terkait lambung sebagai -reservoir makanan, -proses mengeluarkan makanan, atau -terkait peran lambung sebagai penyedia makanan untuk dicerna.

30 (Lanjutan) Infeksi lambung HCL melindungi lambung dari serangan -bakteri, -virus dan -jamur yang masuk bersama makanan, minuman. Bila pertahanan kalah maka terjadi berbagai ragam infeksi gastro-intestinal. 30

31 31 TUMOR LAMBUNG Kanker lambung adalah sebab kematian /tahun di USA. Gangguan pencernaan setelah usia 50 th. sebaiknya diperiksa untuk kemungkinan adanya kanker lambung Gejala:-rasa penuh terus, -sakit sebelum dan sesudah makan, -tidak ada/ hilang nafsu makan, -mudah nausea

32 (Lanjutan) Adanya tumor di bagian atas dekat esophagus akan mengakibatkan obstruksi dan  sulit menelan. Tumor primer lambung kadang tidak menunjuk- kan gejala, baru diketahuai setelah adanya tumor sekunder di tempat lain. Tumor jinak bisa berupa polyps lambung. 32

33 33 ULCERATION HCL bersama getah pencernaan lain yang dihasilkan lambung kadang menyerang lambungnya sendiri. Proteksi terhadap lapisan ini oleh mukus hasil selaput penutup yang ada dan oleh cepatnya regenerasi sel bagian dalam pengganti sel- sel bagian permukaan yang rusak. Banyak hal bisa mengganggu keseimbangan ini Satu di antaranya produk asam HCL lambung yang berlebih.

34 34 PEPTIC ULCERS (TUKAK LAMBUNG) Gangguan lambung yang umum dan serius Bisa akibat: -stress, -cedera (burns, kecelakaan, post-operasi) -infeksi serta, - kadang tanpa alasan jelas) - Selaput lambung bisa rusak akibat obat aspirin atau alkohol, kadang menimbulkan gastritis  ulcerasi.

35 35 GANGGUAN AUTOIMMUNE : Anemia perniciosa timbul akibat lambung gagal menghasilkan intrinsik yang berperan sebagai fasilitator absorpsi vitamin B12, akibat atropi selaput lambung yang juga menimbulkan gagal memproduksi HCL lambung. Perniciosa anemia timbul akibat gangguan autoimun.

36 36 GANGGUAN LAIN: Gangguan lain: Pembesaran lambung bisa: - akibat ulcus peptic chronic - komplikasi stenosis pylorus Vovulus: a twist of the bowel sometime leading to gangrene (by adhesion, or tumor within the bowel)  cito operasi

37 INVESTIGASI LAMBUNG -Barium X-ray untuk pemeriksaan lambung -Gastroscopy, dan -Biopsy bila perlu 37

38 38 KANKER LAMBUNG Tumor ganas primer lambung. Kausa: faktor lingkungan (diet, makan banyak makanan diasinkan, acar, makanan yang diasap). -Megaloblastic anemia -Gastrectomy partial Blood group A. -Usia di atas 40 th, >laki dari wanita. Diagnosis:-X-ray, -gastroscopy, -biopsy.

39 39 KANKER LAMBUNG (Lanjutan) Terapi: Gastrectomy Yang inoperable  radiasi dan obat antikanker. Diagnostik pre-metastasis prognosis dapat diharapkan baik. Di Jepang, dilakukan mass screening dengan gastroscopy, 85% laju harapan hidup rata-rata 5 tahun post-operasi.

40 40 GANGGUAN INTESTINE (USUS) Bisa: (1) struktur abnormal (2) infeksi, parasit (3) tumor dan (4) gangguan aliran darah Defek kongenital: - atresia, - stenosis, - volvulus, - tersumbat muconium (neonatal)  Perlu operasi dini.

41 41 Infeksi dan inflamasi - Gastroenteritis (bakterial, viral - food poisoning - typhoid, cholera - Protozoa: amebiasis, gardiasis, - Parasit cacing: Ascariasis, taenia, ankylostomiasis, oxyuris vermicularis - Ulcerative colitis, Crohn’s disease, - Appendicitis dan - Diverticulitis.

42 42 Gangguan Intestine (lanjutan-1) Tumor-tumor: - jarang - lymphoma - carcinoid (benign) Colon: - Kanker colon - Polyposis  bisa jadi cancer

43 43 Gangguan Intestine (lanjutan-2) Gangguan Aliran Darah -Ischaemia -Obstruksi partial atau komplit arteria dinding abdomen (atherosclerosis, thrombosis, embolism) atau akibat pembuluh terjepit (bisa vovulus. Bisa Intessuseption) atau hernia. Kehilangan darah pada daerah usus  gangrene  segera operasi.

44 44 Gangguan Intestine (lanjutan-3) Obstruction: -Bisa akibat tertekan dari luar, gangguan dinding ususnya (tumor, kanker, Crohn’s disease, atau diverticular). -Sumbatan batu empedu, atau intessuception. Satu yang paling umum adalah paralysis ileus yang mengakibatkan kontraksi usus berhenti dan isi usus tidak bisa didorong  kembung (meteoristis)

45 45 GANGGUAN LAIN: - Peptic ulcers duodenum. - Ulcerasi usus halus terjadi pada infeksi typhoid dan Crohn’s disease.  rentan bleeding dan perforasi. - Ulcerasi usus besar pada amebiasis & ulcerative colitis. - Diverticulitis umumnya tidak bahaya namun bisa meradang.

46 46 Gangguan Intestine (lanjutan 2) Malabsorption dan celiac sprue bisa mengubah selaput lendir usus. Irritabel bowel syndrome berkaitan dengan abdominal pain yang menerus kadang konstipasi kadang diare. Investigasi: -Pemeriksaan fisik -X ray, sigmoidoscopy, colonscopy -Laboratorium feces -Biopsy dari selaput lendirnya.

47 47 GANGGUAN HATI Penyebab utama penyakit hati adalah alkoholic = alcoholic hepatitis dan cirrhosis Di Asia. Afrika: sampai 20% populasi adalah carrier hepatitis virus B, yang mengakibatkan cirrhosis dan primary liver carcinoma. Gangguan hati lain adalah - kongesti, infeksi bakterial dan parasit, - gangguan sirkulasi, dan metabolisme, - keracunan dan autoimune.

48 48 Gangguan Hati (Lanjutan-1) Gagal hati bisa merupakan hasil akhir dari: - acute hepatitis - keracunan - cirrhosis. Gejala umum adalah: - hepatomegali - icterus (jaundice)

49 49 Gangguan Hati (Lanjutan-2) Defek Kongenital, bisa pada: - Saluran empedu (choledochal cyst, terjadi akibat gabungan saluran empedu kecil-kecil di dalam hati) - Biliary atresia Semua memberi tanda: icterus (jaundice)

50 Infeksi & Inflamasi: - Hepatitis viral (A,B, Non-A Non B, C,D dan E) - Hepatitis bakterial - Bakteri dari cholangitis ke hati  abses. - Parasit: -ameba, -schistosomiasis, -fluke, -hydatid. 50

51 51 Gangguan Hati (lanjutan -3) Keracunan: - alkohol, -obat-obat yang dipecah di hati bisa merusak sel hati. Contoh: Usaha bunuh diri dengan obat analgetika - Keracunan jamur, makanan tertentu.

52 52 Gangguan Hati (lanjutan -4) Gangguan Autoimun Masalah utama adalah terjadinya destruksi berlanjut dari sel hati: - Kronik aktif hepatitis - Progressive primary biliary cirrhosis yang lambat laun/menaun. - Sclerosing cholangitis.

53 53 Gangguan Hati (lanjutan – 5) Gangguan Metabolik: -hemochromatosis - Wilson’s disease (copper) Tumor: - Kanker sekunder dari lambung, pancreas, usus besar. - Hepatosplenomegali adalah gejala umum: - lymphoma, - leukemia - Hepatoma (kanker primer ganas) jarang.

54 54 Gangguan Hati (lanjutan – 6) Lain-lain: - Budd-Chiari Syndrome (sumbatan vena)  ascites - Portal hypertension -esophagus varices, -ascites, -cirrhosis

55 55 GANGGUAN SISTEM EMPEDU Sistem bertanggung-jawab terhadap: -pembentukan, -pemekatan, -pengaliran empedu dari hati ke duodenum, -mengalirkan sampah hati dan -mengangkut garam empedu yang diperlukan tubuh ke usus, untuk: membongkar dan menyerap lemak.

56 56 GANGGUAN SISTEM EMPEDU (Lanjutan-1) Empedu diproduksi sel hati dan ditampung di kantung empedu. Lemak yang masuk duodenum, akan memicu sekresi hormon yang akan membuka ampula Vater kontraksi kantung empedu empedu akan mengalir ke usus duodenum  pencernaan lemak. Garam empedu bekerja sebagai emulsifier pemecah lemak menjadi globule kecil mirip susu, sehingga mudah diserap usus kecil.

57 57 GANGGUAN SISTEM EMPEDU (Lanjutan-2) Gangguan: -batu empedu: -cholelithiasis -choledocholithiasis -cholecystolithiasis -choledochocystolithiasis - biliary atresia kongenital -obstruksi saluran: Bisa akibat: -batu, - kanker.

58 58 GANGGUAN PANCREAS Keadaan serius terjadi bila fungsi pancreas sebagai kelenjar terganggu. Gangguan dan Defek Kongenital: 85% cystic fibrosis, tidak dapat menghasilkan getah pencernaan, menimbulkan: - malabsorpsi lemak dan protein  steatorrhea dan kemunduran otot.

59 (Lanjutan-1) Pancreatitis kronik, kadang bisa herediter, bisa menimbulkan diabetes mellitus. Infeksi: - Acute viral infection (> mump virus) - Coxsackie virus (bisa DM), - Echovirus. Tumor: Kanker pancreas adalah umum (sulit terdiag- nose, biasanya ditemukan setelah meluas) 59

60 60 (Lanjutan-2) Trauma: Cedera (terpukul keras)  pancreatitis akut (diduga enzym yang harus masuk duodenum, mencerna sel pancreasnya sendiri). Keracunan dan Obat-Obatan; -Alkoholik, -Obat sulfa, estrogen, HCT, kortikpsteroid,

61 61 (Lanjutan-3) Autoimun: -Penyebab kerusakan pada DM masih tanda- tanya. (mungkin akibat infeksi)  antibodi yang dihasilkan tubuh merusak sel tubuhnya sendiri. Lain-lain: - Pengguna alkohol lama - Batu empedu yang menutup jalan keluar enzym pancreas  Pancreatitis

62 62 INVESTIGASI Hati: -pemeriksaan fisik -liver biopsy - LFT - Ultrasound scanning, -CT scanning Empedu: - Cholecystography

63 (Lanjutan) Pancreas: - Ultrasound scanning - Laboratorium darah atau cairan duodenum: pemeriksaan enzyme pancreas. - Endoscopy - ERCP (Endoscopic Retrograde Cholengio pancreatograpgy) – X-ray untuk melihat sistem empedu berikut ductus pancreas.  Dilakukan bila CT-scan, atau US-scan gagal. 63

64 64 Manifestasi Klinik Gangguan Gastro-intestinal Signs and Symptoms Nausea & vomitingDiarrhea AnorexiaConstipation DysphagiaAchalasia HeartburnAbdominal pain Fecel incontinence Gastrointestinal bleeding: - Hematemesis - Melena - Hematochezia

65 65 (Lanjutan) Constitutional Symptoms Nausea, Vomiting, Diarrhea,Malaise FatiqueFever Night blindnessPallor DiaphoresisDizziness

66 66 CAUSES of DIARRHEA 1.Gangguan Malabsorption: PancreatitisPancreatic carcinoma Crohn’s disease 2.Gangguan Neuromuscular: Irritable bowel syndrome Diabetic enteropathy Hyperthyroidism Caffeine 3.Infectious/Inflammatory: ViralProtozoal (Gardia) BacterialPelvic Inflammation Parasitic

67 67 (Lanjutan-1) 4.Gangguan Mechanical: Incomplte obstruction: - Neoplasm - Adhesions - Stenosis Fecal impaction (scibala) Muscular incompetence Postsurgical effect:- Heal bypass - Gastrectomy - Intestinal resection - Cholecystectomy Diverticulitis

68 68 (Lanjutan-2) 5.Gangguan Non-Specific: Crohn’s diseaseUlceration colitis DiverticulitisDiet Laxative abuseFood allergy AntibioticsLactose intolerance Food addictivesFood poisoning Heavy metal poisoning Drugs containing magnesium and sorbitol

69 69 CAUSES OF CONSTIPATION 1.Gangguan Neurogenic: Central nervous system lesions Cord tumors Cortical, voluntary, or involuntary evacuation Multiple sclerosis Tabes dorsalis Traumatic spinal cord lesions

70 70 (Cont.-) 2.Gangguan Mechanical: Bowel obstruction Extra-alimentary tumors Pregnancy Colostomy

71 71 CAUSES OF CONSTIPATION (Lanjutan-1) 3. Gangguan Muscular: AmyloidosisAtony DermatomyositisDuchenne’s muscular dystrophy HypercalcemiaHyperparathyroidism HyperthyroidismInactivity Metabolic defectsPotassium depletion Severe malnutritionSystemic sclerosis

72 72 CAUSES OF CONSTIPATION (Lanjutan-2) 4. Gangguan Rectal Lesions: Anal fissureHemorrhoids Perirectal abscessRectocele StenosisUlcerative proctitis 5. Akibat Drugs/Diet: AnalgesicsAnesthetic agents AnticholinergicsAnticonvulsants Antacids containing aluminum or calcium AntidepressantsAntihistamines AntipsychoticsBarium sulfate

73 73 CAUSES OF CONSTIPATION (Lanjutan-3) 6.Akibat Drugs/Diet: (Lanjutan) DiureticsHypotensives Iron compoundsLack of dietary bulk Monoamine oxidaseNarcotics inhibitors OpiatesMyocardial infarction (narcotics for pain control) Drugs for Parkinson’s disease Psychotherapeutic drugs Renal failure (fluids restriction, phosphate binders)

74 74

75 75 SESI 9b READING SPECIAL IMPLICATIONS for the THERAPIST DISORDERS of the GASTRO- INTESTINAL SYSTEM

76 76 DESKRIPSI Materi ajar ini membahas tentang hal-hal yang harus menjadi perhatian dan harus dikerjakan para fisioterapis terkait gangguan gastrointestinal

77 77 KOMPETENSI MAMPU: Memahami hal-hal yang harus menjadi perhatian dan dilaksanakan para fisioterapi saat memberi terapi pada pasien dengan berbagai gangguan gastro-intestinal

78 78 POKOK BAHASAN Menjelaskan: Special Implications for the therapist: Disorders of the Gastro-Intestinal System: -Hiatal hernia, Gastro-esophageal Reflux Disease, -Esophageal Cancer, Esophageal Varices -Gastritis, Peptic ulcer, Gastric adenoma,

79 79 Disorders of the Gastro-Intestinal System: (Cont.-) -Malabsorption Syndrome, Intestine ischemia, Botullism, Inflammatory bowel disease, IBS, -Antibiotic- Associated Colitis, Diverticular disease Organic Obstructive Disease, Adynamic or Paralytic ileus, Appendicitis, Hernia, -Primary lymphoma, Peritonitis dan Hemorrhoids

80 80 SPECIAL IMPLICATIONS for the THERAPIST DISORDERS of the GASTRO-INTESTINAL SYSTEM 1.Hiatal Hernia -For any client with known hiatal hernia, the flat supine (which increases intra- abdominal pressure) position and any exercises requiring the Valsava maneuver should be avoided during treatment.

81 81 SPECIAL IMPLICATION... (Cont.-1) -Postoperatively, the client may have chest tubes in place requiring careful observation of the tubes during: -turning and -repositioning and -chest physical therapy to prevent pulmonary complications

82 (Cont.-) Prior to discharge: The client must be warned against activities that: -cause increased intraabdominal pressure, and -given safe lifting instruments. A slow return to function over the next 6 to 8 weeks is advised, 82

83 83 SPECIAL IMPLICATIONS... (Cont.-2) 2.Gastroesophageal Reflux Disease Clients with GERD are often treated in therapy for orthopedic and other conditions. Since education and encouragement are essential to the lifestyle modifications necessary to this condition, the knowledge- able therapist can assist the person implement changes related to diet and exercise.

84 84 Gastroesophageal Reflux Disease (Cont.-1) Any treatment requiring a supine position should be scheduled before meals and avoided just after eating. Modification of position toward a more upright posture may be required if symptoms persist during therapy.

85 (Cont.-) (See also Hiatal Hernia) Activities that increase intra-abdominal pressure, such as: -bending and -vigorous exercise; -constipation, which often accompanies back pain and -other conditions; and -tight clothing must be avoided. 85

86 86 Gastroesophageal Reflux Disease (Cont.-2) After surgery using a thoracic approach, chest physical therapy may be indicated. The presence of GERD requires careful positioning to promote drainage of secretions without causing reflux. This is more readily accomplished when the stomach is empty.

87 87 3. Esophageal Cancer Lymphatic vessels of the esophagus are continuous with mediastinal structures and drain to the lymph nodes from the neck of the celiac axis. Metastasis is via this lymphatic drainage with tumors of the upper esophagus metastasizing to the: -cervical, -internal jugular, and -supraclavicular nodes.

88 88 Continued The therapist may identify changes in lymph nodes, requiring medical referral, during on upper-quarter screening examination. The usual precautions regarding clients with cancer apply to neoplasms of the GI system. The primary concern is the side effects of chemotherapy-induced bone marrow suppression.

89 (Cont.) An exercise regimen including aerobic exercise of a minimal level enhances the immune system and is incorporated whenever possible. 89

90 90 4. Esophageal Varices The primary concerns in therapy are to avoid causing rupture of varices and proper handling of clients with known GI bleeding. Carefully instruct the client in: -proper lifting techniques and -avoid any activities that will increase intra-abdominal pressure.

91 (Cont.) For the client with known esophageal varices, observe closely for signs of behavioral or personality changes. Report increasing: -stupor, -lethargy, -hallucinations, or -neuromuscular dysfunction. 91

92 92 Esophageal Varices (Cont.-1) Watch for asterixis (involuntary jerking movement), a sign of developing hepatic encephalopathy. To assess fluid retention inspect : the ankles and sacrum for dependent edema.

93 93 Esophageal Varices (Cont.-2) To prevent skin breakdown associated with edema and pruritis caution to the client and family members caring for that person: -to avoid using soap when bathing -and to use moisturizing cleansing agents instead.

94 (Cont.-) Precautions must be taken to handle the client gently, turning and repositioning often to keep the skin intact. Rest and good nutrition will conserve energy and decrease metabolic demands on the liver. 94

95 95 5. Gastritis Half of all clients receiving NSAIDs on a chronic basis have acute gastritis (often asymptomatic). The therapist should continue to monitor clients for any symptoms of GI involvement indicating need for medical referral. For the client with known chronic GI bleeding, urge the client to seek immediate attention for recurring. Urge the client to take prophylactic medications as prescribed by the physician.

96 96 Gastritis (Cont.) -Steroids should be taken with: - milk, -food or -antacids to reduce gastric irritation; antacides can be taken between meals and at bedtime. Aspirin-containing compounds should be avoided unless specifically recommended by the physician.

97 97 6. Peptic Ulcer Disease Ulcer presentation without pain occurs more frequently in elderly people and in persons taking NSAIDs for painful musculoskeletal conditions. Any client complaining of GI symptoms should be encouraged to report these findings to his or her physician. Musculoskeletal symptoms may recur after discontinuing the NSAIDs owing to the masking effects of these drugs. One the drug is discontinued, painful symptoms may return in the presence of continued underlying disease.

98 98 6. Peptic Ulcer Disease (Cont.-1) Medical follow-up is required in such situations. Peptic ulcers located on the posterior wall of the stomach or duodenum can perforate and hemorrhage causing back pain as the only presenting symptom. Occasionally ulcer pain radiates to the mid- thoracic back and right upper quadrant, including the right shoulder. Right shoulder pain alone may occur as a result of blood in the peritoneal cavity from perforation and hemorrhage.

99 99 6. Peptic Ulcer Disease (Cont.-2) Back pain may be the only presenting symptom, but this usually accompanied by vomiting of bright-red blood or coffee-ground vomitus. Back pain relieved by antacids is an indication of GI involvement and must be reported to the physician. For the competitive athlete, during the acute episode, anxiety and nervousness may increase gastric secretions.

100 100 Peptic Ulcer Disease (Cont.-2). This effect in combination with poor nutrition (often the athlete has not eaten at all) requires careful monitoring and maximizing the use of medications and food intake with the performance schedule. For the average adult uninvolved in competitive sports, regular exercise as part of stress reduction is essential during remission.

101 101 Peptic Ulcer Disease (Lanjutan-2) National institute on Aging (NIA) (USA) researchers have reported that exercise at least three times a week greatly reduce the risk of GI bleeding. More strenuous forms of exercise such as swimming and bicycling do not provide greater protection from GI bleeding than do more moderate exercises such as walking.

102 Gastric Adenocarcinoma Epigastric or back pain, possibly relieved by antacids, is a frequent complaint that the physician must differentiate from peptic ulcer disease. Generally the first manifestations of carcinoma are caused by distant metastasis when the condition is quite advanced. The therapist may palpate the left supraclavicular lymph node or the client may point out an umbilical nodule.

103 Gastric Adenocarcinoma (Cont.) After surgery: -position changes every 2 hours, -deep breathing, coughing, and -incentive spirometry may be used to prevent pulmonary complications. The semi-Flower position (head of the bed raised 6  12 inc with knees slightly flexed) facilitates breathing and drainage following any type of gastrectomy.

104 Malabsorption Syndrome In the rehabilitation setting or for the acute care client who has not been eating solid foods diarrhea may develop when the person begins to reestablish a normal diet. Prolonged viral conditions can wash out the enzymes normally present in the columnar epithelial cells. Reestablishing normal eating may require additional time to restore the enzymatic homeostasis in the intestines.

105 105 9.Intestine Ischemia Intestinal angina as a result of atherosclerotic plaque – induced ischemia can result in intermittent back pain (usually at the thoracolumbar junction) with exertion. Clinical presentation combined with past medical history, the presence of coronary artery disease risk factors, and the presence of peripheral vascular disease may also alert the therapist to the need for a medical referral if the client has not been medically diagnosed.

106 Botulism The sudden onset of rapidly progressive symptoms associated with botulism is most likely to be reported to a physician rather than to a therapist. However, presentation of acute symetrical cranial nerve impairment (ptosis, diplopia, dysarthria), followed by descending weakness or paralysis of he muscles in the extremities or trunk, and dyspnea from respiratory muscle paralysis, requires immediate medical referral.

107 Botulism (Cont.) After the acute onset and initiation of medical treatment, treatment is as for cranial nerve palsy. In mild to moderate cases, there is a gradual recovery of muscle strength which can take as long as a year after disease onset; in severe cases, there is a 40% mortality.

108 Inflammatory Bowel Disease When terminal ileum involvement in CD produces peri-umbilical pain, referred pain to the corresponding low back is possible. Pain of the ileum is intermittent and perceived in the lower right quadrant with possible associated: -iliopsoas abscess or -ureteral obstruction from an inflammatory mass causing hip, thigh, or knee pain, often with an antalgic gait.

109 Inflammatory Bowel Disease (Cont.-1) Specific objective tests are available to rule out systemic origin of -hip, -thigh, or -knee pain. 25% of all clients with IBD may present with -migratory arthralgias, -monarthritis, -polyarthritis, -or sacroliitis.

110 (Cont.-) It is essential that any time a client presents with: -low back, hip, or -sacroiliac pain of unknown origin, the therapist screen for medical disease by asking a few simple questions about the presence of: -accompanying intestinal symptoms, -known personal history, or -family history for IBD, and -possible relief of symptoms after passing stool or gas. 110

111 Inflammatory Bowel Disease (Cont.-2) Articular symptoms may be the primary clinical manifestation of IBD, intestinal symptoms are usually present but disregarded as part of the whole picture by the client. Treatment of the musculoskeletal involvement follows the usual protocols for each area affected.

112 112 Inflammatory Bowel Disease (Cont.-2) Sulfasalazine used in mild cases of interferes with the absorption and utilization of folic acid, requiring supplement folic acid. Clients taking sulfasalazine may complain of headache, nausea and vomiting. Corticosteroids are an important and effective drug for treating moderate and severe IBD but carry with them all of the complication of prolonged high-dose steroid therapy.

113 113 Inflammatory Bowel Disease (Cont.-4) Hydration and nutrition are always long-tem concerns with clients who have UC or CD. The client must be observed for any signs of dehydration, as well as for any increase or pathologic change in symptoms. Any increase in painful symptoms or increased stool output or stool frequency must be reported to the physician.

114 114 Inflammatory Bowel Disease (Cont.-5) People with IBD may have a characteristic personality susceptible to emotional stresses which precipitate or exacerbate their symptoms. No direct evidence proves the relationship between emotional factors and IBD.

115 115 Inflammatory Bowel Disease (Cont.-5) However, the chronic nature of IBD affecting persons in the prime of life often results in feelings of anger, anxiety, and possible depression. These emotions are important factors in the client’s response to treatment and in modifying the overall course of the disease.

116 Antibiotic- Associated Colitis The primary concern with any client experiencing. Since the onset excessive watery diarrhae is fluid and electrolyte imbalance of this condition may occur up to 1 month after the antibiotic has been discontinued, the client may not recognize the association between current GI symptoms and previous medications.

117 (Cont.-) Anytime someone taking antibiotics or recently completing a course of antibiotics develops GI symptoms, encourage physician notification. 117

118 Irritable Bowel Syndrome Regular physical activity helps relieve stress and assists in bowel function, particularly in people who experience constipation. The therapist should encourage anyone with IBS to continue with the prescribed therapy program during symptomatic periods.

119 Irritable Bowel Syndrome (Cont.) Therapist must be alert to the person with IBS who has developed breath-holding patterns or hyperventilation in response to stress. Teaching proper breathing is important for all daily activities, especially during exercise and relaxation techniques.

120 Diverticular Disease Exercise is on important treatment component during periods of remission. The therapist is instrumental in helping establish an appropriate exercise program. Throughout all activity and exercise, clients with diverticular disease must be careful to avoid activities that increase infra-abdominal pressure to avoid further herniation.

121 Diverticular Disease (Cont.-1) The therapist can provide valuable information regarding appropriate body mechanics and techniques to reduce intra-abdominal pressure for all activities. Back pain can occur as a symptom of this disease. Anyone with back pain of non-traumatic or unknown origin must be screened for medical disease, including possible GI involvement.

122 Diverticular Disease (Cont.-2) If infection occurs and penetrates the pelvic floor or retroperitoneal tissues, abscesses may result causing isolated referred hip or thigh pain. A variety of objective test procedures may be employed by the therapist to assess for iliopsoas abscess formation, including palpation of McBurney’s point, the iliopsoas muscle.

123 Organic Obstructive Disease The therapist may see this client in an acute care setting for ambulation after the obstructive incident has been treated. Dehydration is the primary concern, requiring monitoring of symptoms and vital signs and encouragement of fluid intake throughout therapy. Movement and activity, along with deep- breathing exercise, will aid a promoting abdominal relaxation and restoring bowel function.

124 Adynamic or Paralytic Ileus Anterior lumbar fusion procedures may indirectly cause a functional ileus when the client is unable to ambulate early or remains immobile and inactive for any reason. The short-term use of transcutaneous electrical nerve stimulation (TENS) in the acute care setting may be employed by the therapist to assist in pain control and to encourage mobility. Increased activity stimulates movement of air out of the bowel and helps prevent constipation and the subsequent development of a functional ileus.

125 125 Appendicitis (Cont.-1) In addition to screening for the presence of constitutional symptoms, a variety of objective test procedures may be employed by the therapist including the iliopsoas muscle test and the obturator muscle test. Palpation of McBurney point  Ask the client to cough: localization of painful symptoms to the site of the appendix is typical.

126 126 Appendicitis (Cont.-2) If any of these tests is positive for reproduction of symptoms in the right lower quadrant, a medical referral is necessary if appendicitis is suspected, medical attention must be immediate. The client should be instructed to lie down and remain as quite as possible, taking nothing by mouth (including water); heat is contraindividual.

127 127 Appendicitis (Cont.-2) The physician will also assess for rebound tenderness by pressing down slowly and deeply at an abdominal site away from the painful area. Quickly lifting the examination’s hand allows the indented structures to rebound suddenly. Pain on release of pressure confirms rebound tenderness, a reliable sign of peritoneal inflammation.

128 Hernia Early diagnosis is important in preventing incarceration and strangulation. Any client experiencing chronic cough pregnancy, or back, hip, groin, or sacroiliac pain should be asked. Have you ever been told you have a hernia, or do you think you have a hernia now. For the client recovering from surgical repair of a hernia, heavy lifting and straining should be avoided for 4 to 6 weeks after surgery.

129 129 Hernia (Cont.-1) Transient anesthesia of the skin beneath the hernial incision is a possible postoperative phenomenon. Whether in the presence of an uncorrected hernia or postoperatively, the client should avoid activities and positions that produce painful symptoms associated with the hernia. The therapist should be aware of two complications hat may occur in clients wearing a truss.

130 130 Hernia (Cont.-2) In the client with a small hernia the pressure of the overlying truss on a protruding hernial mass enhances the chances of strangulation by obstructing lymphatic and venous drainage. In a person with a large direct inguinal hernia, the constant overlying pressure of the truss pad on the margins of the hernial defect eventually leads to atrophy of the fascial aponeurotic structures, enlarging the hernial opening and promoting growth of the hernia, thus making subsequent surgical repair more difficult.

131 131 Hernia (Cont.-3) Anytime a person chooses to wear a truss without prior physician evaluation, the therapist is advised to encourage that client to seek medical advice. Although uncommon, psoas abscess can still be confused with a hernia. The therapist may perform evaluative tests to rule out a psoas abscess, iliopsoas palpation, and McBurney’s point, but the physician must differentiate between an abscess and a hernia.

132 132 Hernia (Cont.-4) Psoas abscess is often softer than a femoral hernia and has ill-defined, borders, in contrast to the more sharply defined margins of the hernia. The major differentiating feature is the fact that a psoas abscess lies lateral to the femoral artery, not medial to it as is the case for the femoral hernia.

133 133 Hernia (Cont.-5) Whereas most people do well after surgical repair, some have persistent postoperative pain or discomfort. If a person has had a previous inguinal hernial repair and now presents with painful groin or thigh pain, the physician must differentiate between ilioinguinal nerve entrapment or neuroma of a branch of the nerve severed previously.

134 134 Any person (>older client) with a known hernia complaining of pain, nausea, vomiting, or other new symptom in the anatomic vicinity of the hernia should report these symptoms to the physician to rule out a systemic condition unrelated to the herniation. Congenital muscle weakness complicated by additional risk factors of obesity and increased intra-abdominal pressure should be identified and treated. Hernia (Cont.-6)

135 135 Hernia (Cont.-5) Congenital muscle weakness complicated by additional risk factors of obesity and increased intra-abdominal pressure should be identified and treated. Congenital muscle weakness complicated by additional risk factors of obesity and increased intra-abdominal pressure should be identified and treated.

136 136 Hernia (Cont.-6) Educate clients in proper lifting techniques and precaution to avoid heavy lifting and straining which reduce intra-abdominal pressure as an additional risk factor for the development of hernias and aids in Preventing worsening of an already existing hernia. The mouth-open position as a reminder to breathe properly and to prevent increased intra-abdominal pressure is essential during all lifting procedures

137 137 Hernia (Cont.-7) Obesity as a cause of increased intra-abdominal pressure can be prevented by weight control through exercise. Special care must be taken when treating the client who has a vertical incision. When a vertical incision transects fascial aponeurotic fibers, the incision is made perpendicular to the direction of those fibers.

138 138 Hernia (Cont.-8) Simple muscle contraction, as in: -coughing, -straining, -or turning over bed, tends to distract the wound edges.

139 Peritonitis Special considerations associated with peritonitis are related to the underlying cause (e.g., liver or kidney disease, postoperative, cancer) and resultant complications (e.g., fluid and electrolyte imbalance pulmonary compromise). The client with peritonitis is usually hospitalized and undergoing medical treatment.

140 140 Peritonitis (Cont.-1) The therapist should be familiar with implications associated with the underlying cause and any complications present. Vital signs should be regularly monitored and a semi-Fowler’s position used to help the client breath deeply with less pain to prevent pulmonary complications. Position changes must be accomplished with extreme caution as the slightest movement will intensify the pain.

141 141 Peritonitis (Cont.-2) Watch for signs of dehiscence (separation of layers of a surgical wound) such as the person reporting that: -“something broke losse” or -“ gave way” inside. Follow all safety measures such as keeping the side rails up on the bed if fever and pain disorient the client.

142 Primary Lymphoma Special considerations relate to any complications present with this condition such as: -anemia from intestinal bleeding or -complication associated with radiation therapy.

143 Hemorrhoids Clients involved in any activity requiring increased abdominal support or causing increased intra-abdominal pressure should be questioned as to the presence of hemorrhoids. For clients with hemorrhoids postoperatively, prone position or side lying supported with pillows between the knees and ankles is preferred.

144 Hemorrhoids (Cont.) Supine positioning and sitting for brief periods can be accomplished with a rubber air ring under the buttocks for support. Fluid replacement during exercise is important in the prevention of constipation. Movement and exercise are also extremely helpful in preventing constipation.


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