GANGGUAN LAMBUNG

SESI 9a
GANGGUAN
SISTEM PENCERNAAN
Disusun oleh
dr. Mayang Anggraini Naga
U-IEU (Revisi 2014)
1
DESKRIPSI
Pembahasan materi meliput gangguan
pada sistem gastro-intestinal, pankreas,
hati dan sistem empedu, berserta gangguan
diare
2
KOMPETENSI
Mampu memahami tanda-tanda
gangguan sistem gastro-intestinal,
pankreas, hati dan sistem empedu,
gangguan diare, dan cara pemeriksaannya,
implikasi bagi fisioterapi.
3
POKOK BAHASAN
Menjelaskan:
- Gangguan mulut, esofagus
- Gangguan lambung dan usus
- Gangguan hati, pankreas dan sistem
empedu
- Penyebab diare dan konstipasi
4
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
5
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
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.
7
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
8
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.
9
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.
10
GANGGUAN MULUT (Lanjutan-3)
Terapi:
Orthodontik (orhtodontic appliance braces),
Operasi orthognatic
Operasi sebaiknya pada masa masih
kanak-2 agar lebih efisien dan efektif.
11
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.
12
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.
13
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
14
(Lanjutan)
Keluhan:
-
bisa tanpa gejala,
bisa disfagia
(gangguan perjalanan makanan),
kalau makanan terjebak:
 - inflamasi,
- ulserasi,
- perforasi.
15
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 (PattersonBrown-kelly)
16
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
17
AKHALASIA (Mega-esofagus) (Lanjutan)
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.
18
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.
19
(Lanjutan)
2. Hernia menggelinding (rolling) =
paraesofagus  menimbulkan:
rasa tidak enak dan penuh di
epigastrium post cibum.
Jarang menimbulkan keadaan darurat.
20
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.
21
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.
22
VARICES ESOFAGUS
Sering terjadi perdarahan masif akut.
Causa:
-
ulkus peptikum,
gastritis erosiva,
varises esofagus,
laserasi esofagus.
23
(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
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.
25
(Lanjutan)
Faktor-2 predisposisi:
alkohol,
rokok,
akhalasia,
divertikulum,
esofagitis kronik (leukoplakia dan
displasia),
refluks.
26
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.
27
(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
GANGGUAN LAMBUNG
Gangguan bisa terkait lambung sebagai
-
reservoir makanan,
proses mengeluarkan makanan, atau
terkait peran lambung sebagai
penyedia makanan untuk dicerna.
29
(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
TUMOR LAMBUNG
Kanker lambung adalah sebab kematian
15.000/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
31
(Lanjutan)
Adanya tumor di bagian atas dekat esophagus
akan mengakibatkan obstruksi dan  sulit
menelan.
Tumor primer lambung kadang tidak menunjukkan gejala, baru diketahuai setelah adanya
tumor sekunder di tempat lain.
Tumor jinak bisa berupa polyps lambung.
32
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 selsel bagian permukaan yang rusak.
Banyak hal bisa mengganggu keseimbangan ini
Satu di antaranya produk asam HCL lambung
yang berlebih.
33
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.
34
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.
35
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
36
INVESTIGASI LAMBUNG
-
Barium X-ray untuk pemeriksaan
lambung
Gastroscopy, dan
Biopsy bila perlu
37
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.
38
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.
39
GANGGUAN INTESTINE (USUS)
• Bisa:
(1)
(2)
(3)
(4)
struktur abnormal
infeksi, parasit
tumor dan
gangguan aliran darah
• Defek kongenital:
- atresia,
- stenosis,
- volvulus,
- tersumbat muconium
(neonatal)  Perlu operasi dini.
40
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.
41
Gangguan Intestine (lanjutan-1)
• Tumor-tumor: - jarang
- lymphoma
- carcinoid (benign)
Colon: - Kanker colon
- Polyposis  bisa jadi cancer
42
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.
43
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)
44
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.
45
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.
46
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.
47
Gangguan Hati (Lanjutan-1)
• Gagal hati bisa merupakan hasil akhir dari:
- acute hepatitis
- keracunan
- cirrhosis.
Gejala umum adalah: - hepatomegali
- icterus (jaundice)
48
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)
49
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
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.
51
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.
52
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.
53
Gangguan Hati (lanjutan – 6)
• Lain-lain:
- Budd-Chiari Syndrome (sumbatan vena)
 ascites
- Portal hypertension
-
esophagus varices,
ascites,
cirrhosis
54
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.
55
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.
56
GANGGUAN SISTEM EMPEDU (Lanjutan-2)
• Gangguan:
batu empedu:
cholelithiasis
choledocholithiasis
cholecystolithiasis
choledochocystolithiasis
biliary atresia kongenital
obstruksi saluran:
Bisa akibat: batu,
kanker.
57
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.
58
(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 terdiagnose, biasanya ditemukan setelah meluas)
59
(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,
60
(Lanjutan-3)
• Autoimun:
- Penyebab kerusakan pada DM masih tandatanya. (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
61
INVESTIGASI
• Hati:
- pemeriksaan fisik
- liver biopsy
- LFT
- Ultrasound scanning,
- CT scanning
• Empedu: - Cholecystography
62
(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
Manifestasi Klinik
Gangguan Gastro-intestinal
• Signs and Symptoms
Nausea & vomiting
Anorexia
Dysphagia
Heartburn
Fecel incontinence
Gastrointestinal bleeding:
Diarrhea
Constipation
Achalasia
Abdominal pain
- Hematemesis
- Melena
- Hematochezia
64
(Lanjutan)
• Constitutional Symptoms
Nausea,
Diarrhea,
Fatique
Night blindness
Diaphoresis
Vomiting,
Malaise
Fever
Pallor
Dizziness
65
CAUSES of DIARRHEA
1. Gangguan Malabsorption:
Pancreatitis
Pancreatic carcinoma
Crohn’s disease
2. Gangguan Neuromuscular:
Irritable bowel syndrome
Diabetic enteropathy
Hyperthyroidism
Caffeine
3. Infectious/Inflammatory:
Viral
Protozoal (Gardia)
Bacterial
Pelvic Inflammation
Parasitic
66
(Lanjutan-1)
4. Gangguan Mechanical:
Incomplte obstruction: - Neoplasm
- Adhesions
- Stenosis
Fecal impaction (scibala)
Muscular incompetence
Postsurgical effect:
- Heal bypass
- Gastrectomy
- Intestinal resection
- Cholecystectomy
Diverticulitis
67
(Lanjutan-2)
5. Gangguan Non-Specific:
Crohn’s disease
Ulceration colitis
Diverticulitis
Diet
Laxative abuse
Food allergy
Antibiotics
Lactose intolerance
Food addictives
Food poisoning
Heavy metal poisoning
Drugs containing magnesium and sorbitol
68
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
69
(Cont.-)
2. Gangguan Mechanical:
Bowel obstruction
Extra-alimentary tumors
Pregnancy
Colostomy
70
CAUSES OF CONSTIPATION (Lanjutan-1)
3. Gangguan Muscular:
Amyloidosis
Dermatomyositis
Hypercalcemia
Hyperthyroidism
Metabolic defects
Severe malnutrition
Atony
Duchenne’s muscular
dystrophy
Hyperparathyroidism
Inactivity
Potassium depletion
Systemic sclerosis
71
CAUSES OF CONSTIPATION (Lanjutan-2)
4. Gangguan Rectal Lesions:
Anal fissure
Hemorrhoids
Perirectal abscess
Rectocele
Stenosis
Ulcerative proctitis
5. Akibat Drugs/Diet:
Analgesics
Anesthetic agents
Anticholinergics
Anticonvulsants
Antacids containing aluminum or
calcium
Antidepressants
Antihistamines
Antipsychotics
Barium sulfate
72
CAUSES OF CONSTIPATION (Lanjutan-3)
6. Akibat Drugs/Diet: (Lanjutan)
Diuretics
Hypotensives
Iron compounds
Lack of dietary bulk
Monoamine oxidase Narcotics
inhibitors
Opiates
Myocardial infarction
(narcotics for pain control)
Drugs for Parkinson’s disease
Psychotherapeutic drugs
Renal failure (fluids restriction, phosphate
binders)
73
74
SESI 9b
READING
SPECIAL IMPLICATIONS for the
THERAPIST
DISORDERS of the GASTROINTESTINAL SYSTEM
75
DESKRIPSI
Materi ajar ini membahas tentang hal-hal
yang harus menjadi perhatian dan harus
dikerjakan para fisioterapis terkait gangguan
gastrointestinal
76
KOMPETENSI
MAMPU:
Memahami hal-hal yang harus menjadi
perhatian dan dilaksanakan para fisioterapi
saat memberi terapi pada pasien dengan
berbagai gangguan gastro-intestinal
77
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,
78
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
79
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 intraabdominal pressure) position and any
exercises requiring the Valsava maneuver
should be avoided during treatment.
80
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
81
(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
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 knowledgeable therapist can assist the person
implement changes related to diet and
exercise.
83
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.
84
(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
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.
86
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.
87
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.
88
(Cont.)
An exercise regimen including aerobic exercise
of a minimal level enhances the immune
system and is incorporated whenever
possible.
89
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.
90
(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
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.
92
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.
93
(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
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.
95
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.
96
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.
97
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 midthoracic 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.
98
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.
99
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.
100
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.
101
7.
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.
102
7. 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.
103
8. 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.
104
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.
105
10. 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.
106
10 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.
107
11. 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.
108
11. 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.
109
(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
11. 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.
111
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.
112
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.
113
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.
114
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.
115
12. 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.
116
(Cont.-)
Anytime someone taking antibiotics or
recently completing a course of antibiotics
develops GI symptoms, encourage physician
notification.
117
13. 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.
118
13. 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.
119
14. 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.
120
14. 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.
121
14. 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.
122
15. 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 deepbreathing exercise, will aid a promoting
abdominal relaxation and restoring bowel
function.
123
16. 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.
124
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.
125
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.
126
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.
127
18. 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.
128
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.
129
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.
130
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.
131
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.
132
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.
133
Hernia (Cont.-6)
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.
134
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.
135
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
136
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.
137
Hernia (Cont.-8)
• Simple muscle contraction, as in:
coughing,
straining,
or turning over bed,
tends to distract the wound edges.
138
19. 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.
139
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.
140
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.
141
20. Primary Lymphoma
Special considerations relate to any
complications present with this condition
such as:
anemia from intestinal bleeding or
complication associated with radiation
therapy.
142
21. 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.
143
21. 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.
144