i bc27f85be50b71b1 (163 page)

Pancreatic abscesses and rumors can also be

identified.

·Text or abbreviation in parentheses signifies synonyms to the test names.

Source: Data from LM Malarkey, ME McMorrow (cds). Nurse's Manual of L'lboratory

Tests and Diagnostic Procedures. Philadelphia: Saunders, 2000;524-549.

Laparoscopy

Laparoscopy is the insertion of a laparoscope (a fiberoptic tube) into

the abdominal cavity through a small incision to the left of and above

the umbilicus. To perform this procedure, a local anesthetic is given,

and gas (i.e., nitric oxide or carbon dioxide) is infused into the

abdominal cavity to allow better visualization and manipulation of

the scope. Table 8-9 describes the diagnostic and therapeutic interventions that may be performed with a laparoscope.5 ••

Magnetic Resonance imaging

The use of MRI of the GI system is primarily indicated for imaging of

the liver for hepatic tumors, iron overload, and hepatic and portal

venous occlusion. Otherwise, computed tomography scans are preferred for the visualization of other abdominal organs.7•S Good success, however, has been reported recently in using MRI for defining tissue borders for managing and resecting colorectal rumors' MRI

has also been successful in helping to delineate the etiology of cirrhosis between alcohol abuse and viral hepatitis.1o

Positron Emission Tomography

PET is the use of positively charged ions to create color images of

organs and their functions. Clinical uses of PET for the GI system

include evaluation of liver disease, pancreatic function, and GI cancer.7

GASTROINTESTINAL SYSTEM

523

Table 8-9. Laparoscopic Utilization

Diagnostic

Direct visualization

Define and examine locations of intra-abdominal hemorrhage aher blunt

trauma

Tissue biopsy

Hepatic disease, staging of Hodgkin's disease and non-Hodgkin's lymphoma, metastatic disease, tuberculosis

Fluid aspiration

Determination of the etiology of ascites (free fluid in the peritoneal cavity)

Evaluation of patients with fever of unknown origin

Evaluation of patients with chronic or intermittent abdominal pain

Therapeutic

Aspiration of cyStS and abscesses

Lysis of adhesions

Ligation of fallopian tubes

Ablation of endometriosis or cancer by laser

Cholecystectomy (gallbladder removal)

Appendectomy

Inguinal herniorrhaphy (hernia repair)

Gastrectomy

Colectomy

Vagotomy

Sources: Data from GL EaHwood, C Avunduk (cds). Manual of Gastroenterology (2nd ed).

Boston: Lirde Browll, 1994;27; and Lvt Malarkey, tv1E McMorrow (eds), Nurse's Manu31

of Laboratory Tesrs and Diagnostic Procedures. Philadelphia: Saunders, 2000;537-540,

Pathophysiology

GI disorders can be classified regionally by the structure involved and

ma y consist of the following:

• Motility disorders

• Inflammation or hemorrhage

• Enzymatic dysfunction

• Neoplasms

524

AClITE CARE HANDBOOK FOR PHYSICAL THERAPISTS

Table 8-10. Classification and Common Etiologies or Dysphagia

Classification

Common Etiologies

Obstructive

Benign or malignant (squamous cell carcinoma or adenoma) neoplasms, cervical osteophyte or bone spur.

Esophageal diverticula, rings, and webs are anatomic

abnormalities that disrupt the normal cylindrical shape

of the esophagus.

\'qebs and diverticula tend to occur proximally, whereas rings

generally occur distally at the gastroesophageal junction.

Inflammatory

Tonsillitis, pharyngitis. epiglottitis, esophagitis,

or infectious

gastroesophageal reflux disease.

Candida or herpes viruses (herpes simplex,

cytomegalovirus) are causative agents in chronically

debilitated or iml11unocornpromised patients.

Neurologic

Stroke, parkinsonism, amyotrophic lateral sclerosis,

multiple sclerosis, myasthenia gravis.

Congenital

Tracheoesophageal fistula. esophageal compression by

anomalous artery.

Sources: Data from BJ Bailey. Dysphagia: uncovering the cause when your patient has

trouble swallowing. Consuitanr I 997;37( 1):75; TP Gage. Esophageal Rings, Webs, and

Diverticula. In MM van Ness, SJ Chobanian (eds), Manual of Clinical Problems in Gastroenterology. 805mn: Little, Brown, 1994;32; and SS Shay, MM van Ness. Infectious Esophagitis. In MM van Ness, SJ Chobanian (eds), Manual of Clinical Problems in

Gastroenterology. Boston: Little, Brown, 1994;35.

Esophageal Disorders

Dysphagia

Dysphagia, or difficulty swallowing, can occur from various etiologies

and is generally classified by the causative facrors (Table 8-10). Dysphagia can also be classified by irs locarion as (1) proximal (cervical) or oropharyngeal dysphagia or (2) distal or esophageal dysphagia.

Proximal dysphagia is difficulty swallowing in the upper, or proximal, region of the esophagus and generally resultS from neurologic or neuromuscular etiologies, such as stroke, myasthenia gravis, or polymyositis. I 1-13

Distal dysphagia is difficulty swallowing in rhe lower, or distal,

portion of the esophagus and is usually rhe result of mechanical

obstruction to flow from peptic strictures, mucosal rings, or malig-

GASTROII'ITESTiNAL SYSTEM

525

nam neoplasms, such as squamous cell carCllloma and adenocarcinoma of the esophagus. 11-13

Dysphagia can also be characterized by (J) whether it occurs with

ingestion of solids, liquids, or both; (2) whether it is accompanied by

chest pain or heartburn; (3) whether it is intermirtent, constant, or

progressive; and (4) whether the patient complains of regurgitation or

coughing while eating. The location at which the food becomes stuck

should also be noted. 11.12

Motility Disorders and Angina-Like Chest Pain

Poor esophageal motility from smooth muscle spasms or abnormal

contraction patterns can present as anterior chest pain and mimic

anginal symptOms. Systematic cardiac and GI work-up should establish the differential diagnosis. The following are common esophageal motility disorders":

Achalasia is a neuromuscular disorder of esophageal motility characterized by esophageal dilation and hypertrophy, along with failure of the lower esophageal sphincter to relax after swallowing. A functional obstruction then results from elevated sphincter pressure. A definitive etiology is currently unknown. Suspected causes include

autoimmune dysfunction and genetic predisposition. Clinical manifestations can include episodes of regurgitation, chest pain while eating, and possible aspiration pneumonia.12.15,'6