SESI 9a

GANGGUAN
SISTEM PENCERNAAN

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

TUJUAN INSTRUKSIONAL UMUM

Mampu memahami bentuk-bentuk gangguan sistem
gastro-intestinal, pankreas, hati dan sistem empedu,
gangguan diare, dan cara pemeriksaannya.

TUJUAN INSTRUKSIONAL KHUSUS

& POKOK BAHASAN

Menjelaskan:
-

Gangguan mulut, esofagus

Gangguan lambung dan usus
Gangguan hati, pankreas dan sistem empedu
Penyebab diare dan konstipasi

GANGGUAN SISTEM PENCERNAAN

MULUT:
Bagian sistem organ pencernaan yang
bertugas:
menghancurkan makanan untuk bisa ditelan
mengubah vibrasi dari pita suara (laring)
menjadi speech (bicara) dan
bagian dari saluran pernapasan
Atap mulut: - palatum durum (bagian keras bertulang)
di bagian depan
- palatum molle (bagian yang tak bertulang)
5

Mulut (Lanjutan)

Pada dasar mulut ada lidah yang mengandung

sel-2 khusus yang sensitif terhadap cita rasa
= taste buds.
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.
6

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
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.

GANGGUAN MULUT (Lanjutan)

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.
Terapi: Orthodontik (orhtodontic appliance braces),
Operasi orthognatic
Operasi sebaiknya pada masa masih kanak-2 agar
lebih efisien dan efektif.
8

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.

Gangguan Esofagus (Lanjutan-1)

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.
10

Gangguan Esopfagus (Lanjutan-2)

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
Keluhan: bisa tanpa gejala, bisa disfagia (gangguan
perjalanan makanan), kalau makanan
terjebak: inflamasi, ulserasi, perforasi.
11

 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)

12

AKHALASIA (Mega-esofagus)
Disfagi akibat gangguan motilitas esofagus karena
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
Kelainan tersebut untuk waktu lama mega-esofagus.
Causa: gangguan saraf dan hormonal.
Gejala: disfagia didahului stres emosional berulangulang sakit di belakang sternum, regurgitasi bila
berbaring iritasi kronik Ca.
13

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.
2. Hernia menggelinding (rolling) = paraesofagus
menimbulkan tidak enak dan penuh epigastrium
post cibum. Jarang menimbulkan keadaan darurat.

14

HERNIA HIATUS & ESOFAGITIS (Lanjutan-1)

Esofagitis: 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.
Causa: - alkoholis,
- perokok berat,
- terpajan bahan korosif,
- intubasi lambung untuk waktu lama,
- candidiasis, herpes,
- obat-obatan (KCL, antibiotika kemoterapeutik),
- uremia, pemfigus, epidermolisis bulosa.
15

HERNIA HIATUS & ESOFAGITIS (Lanjutan-2)

Varises esofagus:
Sering terjadi perdarahan masif akut.
Causa:
ulkus peptikum,
gastritis erosiva,
varises esofagus,
laserasi esofagus.
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.
16

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.
Faktor-2 predisposisi:
alkohol, rokok,
akhalasia,
divertikulum,
esofagitis kronik (leukoplakia dan displasia),
refluks.
17

LAMBUNG
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.
Bagian fundus lambung ialah lanjutan dari esofagus,
sedangkan bagian antrum menuju ke duodenum.
Masuk/keluar makanan dikontrol oleh esophageal
sphincters dan pyloric sphincter.
18

GANGGUAN LAMBUNG
Gangguan bisa terkait lambung sebagai reservoir
makanan, proses mengeluarkan makanan, atau
terkait peran lambung sebagai menyedia makanan
untuk dicerna.
Infeksi:
HCL melindungi lambung dari serangan bakteri,
virus dan jamur yang masuk bersama makanan,
minuman.
Bila pertahanan kalah maka terjadi berbagai ragam
infeksi gastro-intestinal.
19

Gangguan Lambung (Lanjutan-1)

Tumor:
Kanker lambung adalah sebab kematian 15.000/tahun
di USA. Gangguan pencernaan setelah usia 50 th.
sebaiknya diperiksa untuk kemungkinan adanya kanker
lambung (rasa penuh terus, sakit sebelum dan sesudah
makan, tidak ada/ hilang nafsu makan, mudah nausea)
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.
20

Gangguan Lambung (lanjutan-2)

Ulceration:
HCL bersama getah pencernaan lain yang dihasilkan
lambung kadang menyerang selaput lambungnya
sendiri.
Proteksi terhadap lapisan ini adalah 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.
21

Gangguan Lambung (lanjutan -3)

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.

22

Gangguan Lambung (lanjutan -4)

Gangguan Autoimmune :
Anemia perniciosa timbul akibat selaput lambung
gagal menghasilkan faktor 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.
Gangguan lain:
Pembesaran lambung bisa:
- akibat ulcus peptic chronic
- komplikasi stenosis pylorus
Gangguan lain: vovulus

23

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

24

KANKER LAMBUNG
Tumor ganas primer lambung.
Causa: 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.
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 ratarata 5 tahun post-operasi.
25

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.
Infeksi dan inflamasi
- Gastroenteritis (bakterial, viral): - food poisoning
- typhoid, cholera
- Protozoa: amebiasis, gardiasis,
- Parasit cacing: Ascariasis, taenia, ankylostomiasis,
oxyuris vermicularis
- Ulcerative colitis, Crohns disease,
- Appendicitis dan diverticulitis.
26

Gangguan Intestine (lanjutan-1)

Tumor-2 : - jarang
- lymphoma
- carcinoid (benign)
Colon: - Kanker colon
- Polyposis bisa jadi cancer
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.
27

Gangguan Intestine (lanjutan-2)

Obstruction:
Bisa akibat tertekan dari luar, gangguan dinding
ususnya (tumor, kanker, Crohns 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)
Gangguan lain:
- Peptic ulcers duodenum.
- Ulcerasi usus halus terjadi pada infeksi typhoid dan
Crohns disease. rentan bleeding dan perforasi.

28

Gangguan Intestine (lanjutan 2)

- Ulcerasi usus besar pada amebiasis & ulcerative colitis.

- Diverticulitis umumnya tidak bahaya namun bisa
meradang.
- 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.
29

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.
Gagal hati bisa merupakan hasil akhir dari:
- acute hepatitis
- keracunan
- cirrhosis.

30

Gangguan Hati (Lanjutan-1)

Gejala umum adalah: - hepatomegali

- icterus (jaundice)
Defek Kongenital, bisa pada:
- Saluran empedu (choledochal cyst, terjadi akibat
gabungan saluran empedu kecil-kecil di dalam
hati)
- Biliary atresia
Semua memberi tanda-2: icterus (jaundice)
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.
31

Gangguan Hati (lanjutan -2)

Keracunan:
- Di luar alkohol, obat-obat yang dipecah di hati
bisa merusak sel hati.
Contoh: Usaha bunuh diri dengan obat analgetika
- Keracunan jamur, makanan tertentu.
Gangguan Autoimun
Masalah utama adalah terjadinya destruksi berlanjut dari
sel hati: - Kronik aktif hepatitis
- Progressive primary biliary cirrhosis
yang lambat laun/menaun.
- Sclerosing cholangitis.
32

Gangguan Hati (lanjutan 3)

Gangguan Metabolik:
hemochromatosis
Wilsons disease (copper)
Tumor: - Kanker sekunder dari lambung, pancreas,
usus besar.
- Hepatosplenomegali adalah gejala umum
lymphoma, leukemia
- Hepatoma (kanker primer ganas) jarang.
Lain-lain: - Budd-Chiari Syndrome (sumbatan vena) ->
ascites
- Portal hypertension -> esophagus varices,
ascites, cirrhosis
33

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.
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. Garam empedu bekerja
sebagai emulsifier pemecah lemak menjadi globule kecil
mirip susu, sehingga mudah diserap usus kecil.
Gangguan: - batu empedu
- biliary atresia kongenital
34
- obstruksi saluran (batu, kanker)

GANGGUAN PANCREAS
Keadaan serius terjadi bila fungsi pancreas sebagai
kelenjar terganggu.
Gangguan dan Defek Kongenital:
85% cystic fibrosis, tidak dapat menghasilkan getah
pencernaan malabsorpsi lemak dan protein
steatorrhea dan kemunduran otot.
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)
35

Gangguan Pancreas (lanjutan)

Trauma: Cedera (terpukul keras) -> pancreatitis akut

(diduga enzym yang harus masuk duodenum,
mecerna sel pancreasnya sendiri).
Keracunan dan Obat-obatan;
Alkoholik
Obat sulfa, estrogen, HCT, kortikpsteroid,
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.
36

INVESTIGASI
Hati: -

pemeriksaan fisik
- liver biopsy
LFT
Ultrasound scanning, CT scanning
Empedu: - Cholecystography
Pancreas: - Ultrasound scanning
- Laboratorium darah atau cairan duodenum:
pemeriksaan enzyme pancreas.
- Endoscopy
- ERCP (Endoscopic Retrograde Cholengiopancreatograpgy) X-ray untuk melihat
sistem empedu berikut ductus pancreas.
Dilakukan bila CT-scan, atau US-scan gagal.

37

Manifestasi Klinik Gangguan Gastro-intestinal

Signs and Symptoms
Nausea & vomiting
Diarrhea
Anorexia
Constipation
Dysphagia
Achalasia
Heartburn
Abdominal pain
Fecel incontinence
Gastrointestinal bleeding: - Hematemesis
- Melena
- Hematochezia

38

Manifestasi Klinik Gangguan Gastro-intestinal (Lanjutan)

Constitutional Symptoms
Nausea,
Vomiting,
Diarrhea,
Malaise
Fatique
Fever
Night blindness
Pallor
Diaphoresis
Dizziness
39

CAUSES of DIARRHEA
1. Gangguan Malabsorption:
Pancreatitis
Pancreatic carcinoma
Crohns disease
2. Gangguan Neuromuscular:
Irritable bowel syndrome
Diabetic enteropathy
Hyperthyroidism
Caffeine
3. Infectious/Inflammatory:
Viral
Protozoal (Gardia)
Bacterial
Pelvic Inflammation
Parasitic

40

CAUSES of DIARRHEA (Lanjutan-1)

4. Gangguan Mechanical:
Incomplte obstruction: Fecal impaction (scibala)
Muscular incompetence
Postsurgical effect:
Diverticulitis

neoplasm
adhesions
Stenosis

Heal bypass
Gastrectomy
Intestinal resection
Cholecystectomy

41

CAUSES of DIARRHEA (Lanjutan-2)

5. Gangguan Non-Specific:
Crohns disease
Ulceration colitis
Diverticulitis
Diet
Laxative abuse
Food allergy
Antibiotics
Lactose intolerance
Food addictives
Food poisoning
Heavy metal poisoning
Drugs containing magnesium and sorbitol

42

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
2. Gangguan Mechanical:
Bowel obstruction
Extra-alimentary tumors
Pregnancy
Colostomy
43

CAUSES OF CONSTIPATION (Lanjutan-1)

3. Gangguan Muscular:
Amyloidosis
Atony
Dermatomyositis
Duchennes muscular dystrophy
Hypercalcemia
Hyperparathyroidism
Hyperthyroidism
Inactivity
Metabolic defects
Potassium depletion
Severe malnutrition
Systemic sclerosis

44

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
Antacids containing aluminum or calcium
Anticholinergics
Anticonvulsants

45

CAUSES OF CONSTIPATION (Lanjutan-3)

6. Akibat Drugs/Diet: (Lanjutan)

Antidepressants
Antihistamines
Antipsychotics
Barium sulfate
Diuretics
Hypotensives
Iron compounds
Lack of dietary bulk
Monoamine oxidase inhibitors
Narcotics
Opiates
Myocardial infarction (narcotics for pain control)
Drugs for Parkinsons disease
Psychotherapeutic drugs
Renal failure (fluids restriction, phosphate binders)
46

47

48

SESI 9b

SPECIAL IMPLICATIONS for the

THERAPIST
DISORDERS of the GASTROINTESTINAL SYSTEM
49

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

50

TUJUAN INSTRUKSIONAL UMUM

Mampu memahami hal-hal yang harus menjadi
perhatian dan dilaksanakan para fisioterapi saat
memberi terapi pada pasien dengan berbagai
gangguan gastro-intestinal

51

TUJUAN INSTRUKSIONAL KHUSUS

& 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,
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

52

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.
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
Prior to discharge, the client must be warned against
activities that cause increased intra-abdominal pressure
and given safe lifting instruments. A slow return to
function over the next 6 to 8 weeks is advised,

53

SPECIAL IMPLICATIONS for the THERAPIST

DISORDERS of the GASTRO-INTESTINAL SYSTEM (Lanjutan-1)

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.
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.
54

Gastroesophageal Reflux Disease (Lanjutan)

(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.
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.
55

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.
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.
An exercise regimen including aerobic exercise of a
minimal level enhances the immune system and is
incorporated whenever possible.
56

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.
For the client with known esophageal varices, observe
closely for signs of behavioral or personality changes.
Report increasing stupor, lethargy, hallucinations, or
neuromuscular dysfunction. Watch for asterixis
(involuntary jerking movement0, a sign of developing
hepatic encephalopathy.
To assess fluid retention, inspect the ankles and sacrum
for dependent edema.
57

Esophageal Varices (Lanjutan)

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.
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.

58

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. 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.
59

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 ulcer disease. 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.
60

Peptic Ulcer Disease (Lanjutan-1)

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.
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. 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.
61

Peptic Ulcer Disease (Lanjutan-2)

For the average adult uninvolved in competitive sports,

regular exercise as part of stress reduction is essential
during remission.
National institute on Aging (NIA) 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 has walking.

62

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.
After surgery, position changes every 2 hours, deep
breathing, coughing, and incentive spirometry may be
used to prevent pulmonary complications. The semiFlower position (head of the bed raised 6 -> 12 in. with
knees slightly flexed) facilitates breathing and drainage
following any type of gastrectomy.)
63

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.
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.
64

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.
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.
65

11. Inflammatory Bowel Disease

When terminal ileum involvement in CD produces periumbilical 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. 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. 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

66

Inflammatory Bowel Disease (Lanjutan-1)

family history for IBD, and possible relief of symptoms

after passing stool or gas. 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.
Sulfasalazine used in mild cases of IBD 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 jigh-dose steroid
therapy.
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Inflammatory Bowel Disease (Lanjutan-2)

People with IBD are known to have low bone mineral

content. Low bone mineral density (BMD) may be more
characteristic of CD than of UC, but no consistent
differentiation has been made between CD and UC in
this regard.
It is always important for the therapist to know what
medications clients are taking so that the first sign of
possible side effects will be recognized and the physician
alerted.
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.
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Inflammatory Bowel Disease (Lanjutan-3)

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.
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 clients
response to treatment and in modifying the overall
course of the disease.
69

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. Anytime
someone taking antibiotics or recently completing a
course of antibiotics develops GI symptoms, encourage
physician notification.

70

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.
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.
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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. 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.
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Diverticular Disease (Lanjutan)

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 McBurneys point, the iliopsoas muscle.
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 deep-breathing
exercise, will aid a promoting abdominal relaxation and
73
restoring bowel function.

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.
74

17. Appendicitis
When appendicitis is atypical the client may not
recognize the need for medical attention but will report
the symptoms to the therapist.
Early recognition o the need for medical referral is
important. In an athletic training or physical therapy
setting, appendicitis may present with symptoms of right
thigh, groin (testicular) pain, pelvic pain, or referred pain
to the hip.
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.
75

Appendicitis (Lanjutan)

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.
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
examinations hand allows the indented structures to
rebound suddenly. Pain on release of pressure confirms
rebound tenderness, a reliable sign of peritoneal
inflammation.
76

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.
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.
77

Hernia (Lanjutan-1)

The therapist should be aware of two complications that

may occur in clients wearing a truss.
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. Anytime
a person chooses to wear a truss without prior physician
evaluation, the therapist is advised to encourage that
client to seek medical advice.
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Hernia (Lanjutran-1)

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 McBurneys
point, but the physician must differentiate between an
abscess and a hernia.
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.
Whereas most people do well after surgical repair, some
have persistent postoperative pain or discomfort.

79

Hernia (Lanjutan-2)

If a person has had a previous inguinal hernial repair and

now presents with painful groin or thigh pain, the
physician must differentiate between ilioingunal nerve
entrapment or neuroma of a branch of the nerve severed
previously. 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.
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

80

Hernia (Lanjutan)

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.
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.
Simple muscle contraction, as in coughing, straining, or
turning over bed, tends to distract the wound edges.
81

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.
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-Fowlers position used to help the client breath
deeply with less pain to prevent pulmonary
complications.

82

Peritonitis (Lanjutan)

Position changes must be accomplished with extreme

caution as the slightest movement will intensify the pain.
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.
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.
83

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.
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.
84