GI Dysfunction and Somatic Pain Mimicry

Objectives

• The presentation is to review key signs and symptoms of gastrointestinal (GI) and hepatobiliary dysfunction.
• It will discuss common GI and hepatobiliary pathologies that may mimic somatic pain.

Psychoneuroimmunology

• There is a relationship between the enteric system, the immune system, and the brain.
• Two-thirds of all immune activity occurs in the gut.
• This concept relates to disorders like fibromyalgia, SLE, RA, and chronic fatigue syndrome (CFS).

GI Disorders and Referred/Mimicked Pain

• GI disorders can cause referred pain in several regions, mimicking musculoskeletal (MSK) issues.
• Regions of referred pain include the sternum, neck, shoulder, scapula, low back, sacrum, groin, and hip.
• GI conditions can cause referred pain to the back and shoulder, such as upper back pain.
• Arthritis and migratory arthralgias occur in approximately 25% of patients with Crohn’s disease.
• Appendicitis, Crohn’s disease, and ulcerative colitis can cause iliopsoas muscle abscesses, leading to hip, thigh, or groin pain.
• Antibiotics and NSAIDs are medications can induce GI symptoms.

GI Manifestations

• Common GI manifestations include abdominal pain, dysphagia, odynophagia and GI bleeding.
• GI bleeding can present as emesis or melena.
• Further GI manifestations are altered eating habits, including anorexia, nausea, and vomiting.
• GI disorders can present as arthralgia, neurologic disorders and early satiety with weight loss.
• Other GI manifestations include constipation, diarrhea, fecal incontinence, referred shoulder pain, and epigastric pain that radiates to the back.

Anorexia, Nausea, and Vomiting

• Anorexia, nausea, and vomiting can be signs of a GI disorder or other conditions.
• Other potential origins are systemic infections, uremia and emotional responses.
• Further causes are motion sickness, elevated ICP, overindulgence of food or drugs, and pain.
• Anorexia and vomiting can have serious complications, including dehydration, acidosis, and malnutrition.
• Nausea is an unpleasant subjective feeling stimulated by distention, irritation, and inflammation of the digestive tract, as well as smells, visual images, pain, and chemical toxins or drugs.
• Vomiting may be triggered by distention or irritation in the digestive tract and stimuli from various parts of the brain.
• Vomiting is induced by unpleasant sights or smells, ischemia, pain or stress, vestibular issues, and increased intracranial pressure. Projectile vomiting without preceding nausea may also prompt the vomiting reflex.
• Stimulation of the chemoreceptor trigger zone and drugs, toxins, and chemicals can induce vomiting.

Characteristics of Vomitus

• Presence of blood in vomit, known as hematemesis, can indicate coffee ground vomitus.
• Brown granular material indicates the action of HCl on hemoglobin, and hemorrhage indicates that red blood may be present in the vomit.
• Yellow or green-stained vomitus are caused by bile from the duodenum.
• Deep brown vomit indicates content from the lower intestine.
• Recurrent vomiting of undigested food indicates a problem with gastric emptying or infection.

Diarrhea

• Diarrhea features excessive frequency of stools, usually with loose or watery consistency
• Diarrhea may be acute or chronic and accompanied by nausea and vomiting when infection or inflammation develops.
• Cramping pain can occur during a bout of diarrhea.
• Prolonged diarrhea may lead to dehydration, electrolyte imbalance, acidosis, and malnutrition.

Common Types of Diarrhea

• Large-volume diarrhea can be secretory or osmotic.
• The stool is watery resulting from secretions into the intestine from the plasma and is often related to infection.
• Small-volume diarrhea is often caused by inflammatory bowel disease.
• Stool may contain blood, mucus, or pus and may be accompanied by abdominal cramps.
• Steatorrhea involves frequent bulky, greasy, loose stools with a foul odor and is characteristic of malabsorption syndromes like celiac disease and cystic fibrosis.
• With steatorrhea, fat is usually the first dietary component affected, interferes with the digestion of other nutrients, and the abdomen is often distended.

Blood in Stool

• Blood may occur in normal stools, diarrhea, constipation, tumors, or inflammatory conditions.
• Frank blood originates usually from lesions in rectum or anal canal-
• Occult blood are small hidden amounts detectable with a stool test and may be caused by small bleeding ulcers.
• Melena causes stool that is dark-colored and tarry.
• It may result from significant bleeding in the upper digestive tract.

Gas

• Gas develops normally due to swallowed air, bacterial action on food, certain foods, or alterations in motility.
• Excessive gas may manifest as eructation, borborygmus, abdominal distention and pain, and flatulence.

Constipation

• Constipation is a condition of less frequent bowel movements than normal.
• Characterized by small, hard stools, the causative problem is acute or chronic.
• It may be caused by decreased peristalsis.
• Periods of constipation may alternate with periods of diarrhea.
• Chronic constipation may cause hemorrhoids, anal fissures, or diverticulitis.

Causes of Constipation

• Constipation can be triggered by weakness of smooth muscle, inadequate dietary fiber and/or fluid intake.
• Ignoring the defecation reflex, Immobility and neurological disorders can result in constipation.
• Certain Medications (opiates, antacids, and iron supplements) as well as obstructions caused by tumors or strictures may also result in constipation.

Pain: Visceral Pain Characteristics

• Visceral pain creates a burning sensation and may occur with inflammation and ulceration in the GI tract.
• Patients experience a dull, aching pain due to stretching of liver capsule.
• Cramping or diffuse pain occurs with inflammation, distention, and stretching of the intestines.
• Colicky pain features sharp spasms that are wave-like and often severe.
• Colicky pain starts and stops quickly due to intermittent contractions and can occur in response to severe inflammation or obstruction.

Pain: Somatic Pain

• Somatic pain receptors are directly linked to spinal nerves.
• Causes reflex spasm of overlying abdominal muscles.
• Stays steady, intense, and well-localized to a specific abdominal area.
• Arises from Involvemen or inflammation of the parietal peritoneum.
• Rebound tenderness occurs over the specified area of inflammation and intensifying when pressure is released -- appendicitis is an example.

Malnutrition

• Malnutrition may be limited to a specific nutrient or generalized deficiency.
• Limited malnutrition can be Vitamin B12 or iron deficiency related.
• Generalized malnutrition stems from systemic conditions.
• It occurs due to chronic anorexia, vomiting, and diarrhea, stemming from causes such as chronic inflammatory bowel disorders and cancer treatments.

Dysphagia

• Dysphagia is difficulty swallowing.
• Presentation involves pain with swallowing (odynophagia).
• Can arise from the inability to swallow larger pieces of solid material and difficulty swallowing liquids in general.
• May trigger choking and coughing with the attempt to shallow.
• Related to a Neurological deficit, Muscular disorder or Mechanical obstruction.
• Neurological deficits are related to stroke or TBI issues.
• Muscular disorder may be secondary to trauma or Commonly occurs following anterior cervical fusions.
• With mechanical obstruction stenosis (narrowing of the esophagus) is developmental or acquired in nature.

Esophageal Cancer

• Esophageal cancer usually originates in distal esophagus.
• Significant dysphagia occurs in later stages and presents with the patient reporting upper back pain.
• Swallowing food may worsen symptoms.
• Poor prognosis due to late manifestations.
• Often associated with chronic irritation related to chronic esophagitis, Achalasia or Hiatal hernia.
• Can come about from Alcohol abuse and/or smoking.

Hiatal Hernia

• Part of the stomach protrudes into the thoracic cavity.
• Food may lodge in pouch of the hernia.
• Causes inflammation of the mucosa, reflux of food up the esophagus and chronic esophagitis. Signs include heartburn, constant belching and increased discomfort when lying down.
• Patients may have substernal pain that may radiate to shoulder and jaw

Gastroesophageal Reflux Disease (GERD)

• Periodic reflux of gastric contents into distal esophagus causes erosion and inflammation.
• Often occurs with hiatal hernia.
• Increased symptoms when laying down, especially after eating.
• Avoid consumption of caffeine, fatty and spicy foods and alcohol, smoking, certain drugs to reduce symptoms.
• Use of medication assists in reducing reflux & inflammation.
• Patients may experience symptoms in the form of atypical MI symptoms.

Gastritis: Acute Gastritis

• Gastric mucosa is inflamed, possibly ulcerated and bleeding.
• Caused by infection by microorganisms, allergies to foods, irritating foods and excessive alcohol intake.
• Originates with the ingestion of aspirin, other NSAIDs or corrosive/toxic substances as well as radiation or chemotherapy.
• Basic signs of GI irritation are anorexia, nausea, vomiting and Hematemesis caused by bleeding.
• Patients may experience Epigastric pain, cramps or general discomfort with infection and diarrhea.
• Acute gastritis is usually self-limiting.

Peptic Ulcer: Gastric and Duodenal Ulcers

• Most commonly originates from H. pylori infection, and is associated with proximal duodenum
• Patients experience ulcers due to breakdown of - mucosal barrier.
• Decreased mucosal defense is more common in gastric ulcer development, where increased acid secretion is a predominant factor in duodenal ulcers.

Gastric and Duodenal Ulcers

• Damage to mucosal barrier is associated with Inadequate blood supply due to vasoconstriction.
• Stress, smoking, shock, circulatory impairment and rapid regeneration of epithelium can also cause ulcer formations.
• Excessive glucocorticoid secretion or medications and ulcerogenic substances (Aspirin, NSAIDs, alcohol) that break down mucous occur as well.

Complications of Ulcers

• Hemorrhage is relatively common because erosion of blood vessels.
• It may be the first sign.
• Perforation occurs as the ulcer erodes completely through the wall.
• Chyme can enter the peritoneal cavity, resulting in chemical peritonitis.
• Obstruction results from increased scar tissue at the ulcer site.

Ulcer Symptoms

• "Heartburn" or epigastric pain as well as Aggravation by food.
• With duodenal ulcer, patients experience night pain in a time range from midnight to 3:00 AM. Patients may also Radiating back and/or right shoulder pain with the usual complaints such as nausea or anorexia and passing blood in stool.

Gastric (Stomach) Cancer

• Most patients are asymptomatic in early stages.
• Leading to late diagnosis and poor prognosis.
• Risk stems from Genetic predisposition, H/o pernicious anemia, eating too much smoked foods, nitrites etc.
• Other Signs/symptoms include Epigastric pain and weight loss.
• Patient report Dysphagia, and an Iron deficiency stems to Hematemesis or melena.
• May develop palpable mass on the left supraclavicular lymph node

Acute Pancreatitis

• Pancreatitis is medical emergency because the pancreas lacks fibrous capsules, in response Destructive actions may progress to surrounding tissues.
• Substances released by necrotic tissues release inflammatory compounds resulting in Hypovolemia and circulatory collapse
• Chemical peritonitis results in bacterial peritonitis, potentially leades to Adult respiratory distress syndrome and acute renal failure.
• Potential causes includes Gallstones, Alcohol abuse and Sudden onset by taking too much fat or alcohol food

Causes of Acute Pancreatitis Symptoms

• Primary symptoms are Severe epigastric pain radiating to the back.
• Low-grade fever may present until infection develops, in which a High temp is present.
• Abdominal distention may happen and create decreased bowel sounds, as a result of Decreased peristalsis and paralytic ileus.
• Signs of shock may occur originating from Hypovolemia

Symptoms of Chronic Pancreatitis

• Patients experience recurring Epigastric pain radiating to the back and Upper left as well asLumbar pain.
• Can also cause Nausea, vomiting, Weight loss and Oily/fatty and Clay stool.

Pancreatic Cancer

• It is typically asymptomatic until well advanced.
• risk includes smoking, Obesity and Liver cirrhosis due to Chronic pancreatitis.
• Symptoms includes Epigastric and back pain with Jaundice and anorexia and weight loss
• Other symptoms involve Light-colored stools, and constipation.

Celiac Disease

• A malabsorption syndrome with A genetic link and Primarily diagnosed in childhood.
• Manifestation may occur later in an adults
• It occurs because of Defect in Intestinal enzyme where Patients have difficulty when adding cereals to their diet.
• First signs typically appear at about 4 - 6 months of age.
• Prevents the full digestion of gliadin, damaging the intestinal villi and resulting in and Malnutrition

Manifestations of Celiac Disease

• Can occur Steatorrhea along with Muscle wasting which create Failure to gain weight.
• Other symptoms are Irritability and malaise.
• Diagnosis requires Diagnosis from sample tissue and various blood tests.

Chronic Inflammatory Bowel Disease (IBD)

• Major condition are Crohn’s disease and Ulcerative colitis, all due to an Autoimmune defect.
• IBD manifests as skin, eye and joint symptoms and displays similar symptoms.

Crohn’s Disease

• Any part can get affected but the digestive tract is more prevalent because of the inflammation.
• Patients report skip lesions where Affected areas separated by areas of normal tissue.
• This can be a result of Damage inhibiting Processing a lack of adequate nutrition.
• Can develop Progressive inflammation that can affect the motility and cause restricted areas.
• With this lack of digestion, leads to Hypoproteinemia, avitaminosis, malnutrition,, ad possibly to steatorrhea.
• Complications are Adhesions of loops to develop and fistulas.
• Children experience Delayed in maturation and sexual development.

Ulcerative Colitis

• Inflammation starts in the rectum and Progresses through the colon resulting in extreme symptoms (toxic megacolon)
• Can results in frequent passing of mucus and painful cramps of up to 12 times a day.
• Mucosa and submucosa becomes inflamed, due to decreased Electrolyte fluid

What Crohn’s and Ulcerative Colitis Have in Common

• Diarrhea and Constipation with a Fever, leading to Abdominal pain when Rectal (anal passage) Bleeding during their Night sweats.
• Due to this their Bodies decrease in weight .
• Skin becomes dry, Uveitis which creates in the The irritation of both eyes.

Irritable Bowel Syndrome (IBS)

• Occurs with a abnormal Inflammatory reaction.
• Can develops Gastrointestinal trouble and Visceral (internal hypersensitivity).
• Other infections are Overgrowth bacteria infection, Food poisoning resulting from the infection as well as Physiciatric disturbance.

IBS: Manifestations and Diagnosis

• Results in Lower abdominal pain, Diarrhea and Constipation in alternating order.
• Bloating that creates low back pain; especially if constipation is present.

Anorexia symptoms

General pain begins in the Upper part of the Naval and Vomiting.

• Pain creates serious pain that travels to the Lower Right of the Body or pain in the thigh, groin, or testicle
• Diagnosis requires Positive hop test and a sign of Dysuria

Appendicitis Progression

• After rupture, Pain temporarily subsides which makes for pain. The patient may indicate a generalized Severe pain and guarding resulting in a fever and inflammation . Patients report a Rigid abdomen which is detected by the development of perotonits and abdominal issues that cause reduced blood pressure

Diverticular Disease

• When a layer of tissue pushes the layer of the colon.
• This is known as hernia action.
• When this hernia action causes Asymptomatic movement.
• It also leads to inflammation creating Diverticulitics.
• This process is caused to gaps being created where Weak points exists.
• At times there are no symptoms, however, the patient does express Infection.

Diverticulitis Symptoms

• Discomfort, pain and elevated levels and causes Lower pain and uneasiness.

Symptoms of Collorectal

• Early identification is key as Collorectal patients occur primarily in the in a persons later years, due to Gene transfers that develop from Familial history and from ulcerative . Can derive from genetics where family can inherit the cancer or the patient consumes food without fiber

Collorectal General Complications

• Changes depends on the Initial diagnosis with symptoms consisting of Changes relating to diarrhea,
• Patients experience Fatigue, weight loss and anemia.
• Early signs consists of hemorrhoids .
• Other sensations consist of Abdominal and hip pain, and back sensation.

Late and Serious Complications of Collorectal Cancer

• Constipation results in a restricted movement and discharge.
• Patients endure Nausea which causes a drastic Reduction in body bulk.
• Fever is a less common trait.
• In general patients endure tiredness as well as hard and heavy respiration

Intestinal Obstruction

• Absence in motion leads to intestine restriction.
• Its typically stems from adhesions, a hernia to a tumour in the body.
• Problems with the intestines movement or non-movement

Intestinal Obstruction Complications

• An over amount of fluids can distend the body during obstruction, this increases stress and force.
• Body try's to eject substances to the colon which can lead to an electrolyte imbalance.
• Blood walls can constrict.
• Body can cause intestinal swelling which can lead to peritonitis ( bacterial production).
• Intestinal wall becomes necrotic causing bacteria and toxins to spill into the nearby spaces in the abdomen this leads to infection called septicemia.

More Obstruction complications

• Can lead to surgery abdominal injury which requires a high dose of spinal anesthesia.
• Results from high exposure of radiation or infection of the kidneys can result with a SCI.
• Caused from hernia, tissue tears or tumors as well.
• Conditions such as Crohn can cause this effect.

Specific Intestional Obstrucion Complications

• Can lead to small intestines damage, due to colicky pains that result in an inconsistent bowel action that gets worst during Bile discharge.
• When body fails it fails into hypovolemia

Peritonitis (tissue tearing)

• This condition may develop as enzymes leak out from the intestines which is caused from enlargement or perforated section of the intestines to rupture.
• This will result from other foreign complications or factors that causes an Rupture.

Causes of Peritonitis

• Starts bacterial effects that damage from Trauma, A ruptured appendix.
• If non-natural agents comes in contact with abdominal fluids, or the Infection can also creates issues that results with the fall of the Ovaries which gets infected by fallopian tubes.

Results of Tissue Tear (Peritonitis) Complications

• Severe abdominal aches with continuous and ongoing pain
• Results In reduced of body pressure due to blood loss and fever or a high heart rate
• Patients start passing pus/ or yellow discharge and creates a form of swelling near the body.

Review of GI and hepatobiliary dysfunction signs and symptoms. Discussion of GI pathologies mimicking somatic pain. Focus on referred pain patterns and the relationship between the enteric system, immune system, and brain.