screening of git.pptx

SCREENING FOR GASTROINTESTINAL DISEASE Anisa Differential Diagnosis PHYSICAL THERAPISTS Screening for Referral 4th edition. ABDOMINAL PAIN PRIMARY GI VISCERAL PAIN PATTERN Epigastric region:  occurs from midsternum to xiphoid...

SCREENING FOR GASTROINTESTINAL DISEASE Anisa Differential Diagnosis PHYSICAL THERAPISTS Screening for Referral 4th edition. ABDOMINAL PAIN PRIMARY GI VISCERAL PAIN PATTERN Epigastric region:  occurs from midsternum to xiphoid process  from heart, esophagus, stomach, duodenum, gallbladder, liver & other mediastinal organs  T3 to T5 sympathetic nerve distribution Periumbilical region (T9 to T11 nerve)  impairment of small intestine, pancreas, appendix.  Pain around umbilical & low back pain lower abdominal region (hypogastrium)  from the large intestine or colon  innervated by T10 to L2  Referred GI Pain Patterns  Liver, diaphragm and pericardium (C3-C5) – refer pain to the shoulder  Gallbladder, stomach, pancreas and small intestines (T6- T9) – refer pain to the mid back and scapula  Colon, appendix and pelvic viscera (T10-T11)  Sigmoid colon, rectum, ureters and testes (T11-L1, S2-S4) – refer pain to the pelvis, flank, low back or sacrum DYSPHAGIA  sensation of food catching or sticking in the esophagus  Achalasia is process by which circular and longitudinal muscular fibers of lower esophageal sphincter do not relax  Radiological finding: Mega esophagus or birds beak ODYNOPHAGIA  pain during swallowing  caused by esophagitis or esophageal spasm  upright positioning relieves esophagitis  CASE EXAMPLE  An obese 88 year old woman with a total knee replacement (TKR) was referred for rehabilitation because of loss of motion, joint swelling, and persistent knee pain  Over a period of 2 or 3 weeks, each daughter commented on how much weight the mother had lost.  When questioned, the client complained of a loss of appetite and difficulty in swallowing, but she had been evaluated and treated only for her knee pain by the orthopedist WHAT SHOULD THERAPIST DO??  Patient was encouraged to contact her family doctor for evaluation of these red flag symptoms and was subsequently diagnosed with esophageal cancer. Gastrointestinal (GI) Bleeding  GI bleeding can appear as mid thoracic back pain with radiation to right upper quadrant.  Diagnosis: serial hemoccult & lab test SIGNS AND SYMPTOMS:  Coffee ground emesis (vomit)  Bloody diarrhea  Bright red blood  Melena (dark, tarry stools)  Reddish or mahogany-colored stools  Constipation  condition of prolonged retention of fecal content in the GI tract resulting from decreased motility of the colon or difficulty in expelling stool.  Most common symptom back pain  People with low back pain may develop constipation as a result of muscle guarding and splinting that causes reduced bowel motility.  Pressure on sacral nerves from stored fecal content may cause an aching discomfort in the sacrum, buttocks, or thighs  CASE EXAMPLE  A 29-year-old male presented in the physical therapy clinic with inner thigh pain of the left leg of unknown cause over the last 3 weeks  The pain occurred most often when he had a bowel movement.  training for an iron man competition (swimming, biking, running), but no history of accident or injury  the client reported an inability to get an erection and a tendency toward constipation with hard stools  no clinical signs of muscle weakness, atrophy, or dysfunction. Postural alignment was symmetrical  All provocation tests for hip, spine , sacrum, SI, and pelvis were negative  no red flag history or red flag signs  no signs of vascular compromise  No bladder problems or urinary incontinence.  Knowing that the pudendal nerve is responsible for penile erection, the therapist asked to see the client on his bicycle  Pressure on the nerve from a poorly constructed and minimally padded seat was a possible cause. WHAT SHOULD THERAPIST DO??  advised to change bike seats, change the seat height and tilt, and reassess symptoms in 2 weeks.  Stand up intermittently to relieve perineal pressure  Obturator nerve compression leads to inner thigh pain  Vascular and/or neurologic compromise of the pudendal nerve is the most likely explanation for these symptoms  Diarrhea  abnormal increase in stool liquidity and frequency  Acute diarrhea: fever, cramps, blood or pus in stool => invasive enteric infection  Chronic diarrhea: weight loss is indicated neoplastic or Inflammatory Bowel Disease  FECAL INCONTINENCE  inability to control evacuation of stool Causes  partial obstruction of the rectum (cancer)  colitis  radiation therapy (cervical or uterine cancer )  Hemorrhoidal surgery ARTHRALGIA  Many inflammatory GI conditions have an arthritic component affecting the joints  Asymmetric, migratory and usually only affects one or two joints at a time  Accompanied by fever, malaise, skin rash or lesions, nail bed changes, iritis or conjunctivitis  Usually accompanying symptoms occur 1-3 weeks prior to the onset of joint pain  Peripheral joints (knees > ankles > shoulders > wrists > hands and feet) are most commonly affected  Shoulder Pain  Pain in the left shoulder (Kehr's sign) can occur as a result of free air or blood in the abdominal cavity, such as a ruptured spleen  right shoulder pain when free air or blood is present in abdominal cavity due to liver trauma  Pancreatic disease can refer pain to the shoulder  head of the pancreas is involved, the client could have right shoulder pain  tail of the pancreas is diseased, pain can be referred to the left shoulder  CASE EXAMPLE  A 23-year-old soccer player sustained a blow from the side as he was moving down the soccer field  He fell on his left side with the full force of his own body weight and the weight of the other player on top of him  He reported having "the wind knocked out of me" and sat out on the sidelines for 20 minutes & resume game and completed.  The next morning, he woke up with severe left shoulder pain and stopped by the office of a physical therapist  objective examination was unremarkable for shoulder movement dysfunction, which was inconsistent with the client's complaint of "constant pain”  The client was treated symptomatically and instructed in pendulum exercises to maintain the joint motion RED FLAGS AND SIGNS??  before noon, he collapsed at work and was taken to a hospital emergency department.  A diagnosis of ruptured spleen was made during emergency surgery  Physical therapy intervention was not appropriate in this situation  an immediate medical referral was indicated given the history of trauma, sudden onset of symptoms, left shoulder pain (Kehr's sign), and constancy of pain MURPHY’S PERCUSSION KEHR SIGN  It is for kidney  It is for spleen rupture  Location: costovertebral angle  Below costal margin, upper (post) left quadrant  Pain pattern: localize  Ipsilateral left shoulder pain MURPHYS SIGN MCBURNEYS POINT  For gall bladder (cholecystitis)  For appendicitis  Inferior margin of rib cage  Imaginary line b/w umbilicus (right) & 1/3rd ASIS  Pain during inspiration  Point tenderness  OBTURATOR OR PSOAS  ABSCESS Causes lower abdominal pain  Result from diverticulitis, crohns disease, pelvic inflammatory disease , appendicitis SIGNS AND SYMPTOMS:  Fever  Night sweats  Abdominal pain  Loss of appetite or other Gl upset  Back, pelvic, abdominal, hip, and/or knee pain  Antalgic gait  Palpable, tender mass  GI DISEASES Gastroesophageal Reflux Disease (GERD)  backward movement of stomach acids and other (ACID REFLUX)  Damages the food pipe  Pathology: LES abnormally relax  Typical Symptoms Heartburn Regurgitation with bitter taste in mouth Belching ACHALASIA GERD  Abnormal relaxation of LES  Inability of LES to relax during results in backward flow of normal parastaltic movement acid in esophagus  Radiological: mega esophagus  May result in esophageal or bird beak ulcer/ peptic ulcer  Peptic Ulcer  loss of tissue lining  Structures involve: lower esophagus, stomach, and duodenum  Acute lesions that do not extend through the mucosa are called erosion  Chronic ulcers involve the muscular coat, destroying musculature and replacing it with permanent scar tissue at the site of healing. CAUSES:  GERD  Infection (h.pylori)  NSAIDs  Clinical Signs and Symptoms  "Heartburn" or epigastric pain aggravated by food (gastric ulcer); relieved by food, milk, antacids, or vomiting (duodenal ulcer)  Night pain (12 midnight to 3:00 a.m.)-same relief as for epigastric pain (duodenal ulcer)  Radiating back pain  Stomach pain  Right shoulder pain (rare)  Lightheadedness or fainting  Nausea  Vomiting  Anorexia  Weight loss  Bloody stools  Black, tarry stools Gastrointestinal Complications of NSAIDs  impairment can be asymptomatic until the condition is advanced.  most common side effects:  stomach upset and pain, possibly leading to ulceration  GI effects of NSAIDs are responsible for clients with arthritis  ANTIBIOTIC COLITIS  GI BLUES OF NAUSEA  ANOREXIA FROM DIGITALIS TOXICITY  N’SAW INDUCED ULCERS Clinical Signs and Symptoms Asymptomatic Stomach upset (nausea) and stomach pain Indigestion, heartburn Skin reactions (itching, rash, acne) Tinnitus (ringing in the ears) CNS Changes Renal Involvement New onset back (thoracic) or shoulder pain Melena  Diverticular Disease  Diverticulosis is a benign condition in which the mucosa (lining) of colon balloons out through weakened areas in the wall  Diverticulitis describes the infection and inflammation of the diverticula Clinical Signs and Symptoms generalized abdominal pain often loss of appetite and nausea Left lower quadrant pain Decreased bowel sounds Constipation irregular bowel movements Bloody stools  Appendicitis  inflammation of the vermiform appendix  requiring surgery  rupture may occur, leading to peritonitis. McBurney's Point The palpation point for the iliopsoas muscle is one third the distance between the ASIS and the umbilicus, whereas McBurney's point is halfway between these two points Clinical Signs and Symptoms  Periumbilical and/or epigastric pain  Right lower quadrant or flank pain  Right thigh, groin, or testicular pain  Abdominal muscular rigidity  Positive McBurney's point  Rebound tenderness (peritonitis)  Positive hop test  Anorexia  Dysuria  Low-grade fever  Coated tongue and bad breath  CASE EXAMPLE  32-year-old female university student  She had been referred to physical therapy with the provisional diagnosis: Possible right oblique abdominis muscle tear /possible right iliopsoas muscle tear.  Her history included the sudden onset of "severe pain" in the right lower quadrant with accompanying nausea and abdominal distention.  Aggravating factors: hip flexion, sit-ups, fast walking, and movements such as reaching, turning, and bending.  Painful symptoms could be reproduced by resisted hip or trunk flexion, and tenderness/tightness was elicited on palpation of the right iliopsoas muscle compared with the left.  A neurologic screen was negative  constitutional symptoms including fatigue, night sweats, nausea, and repeated episodes of severe, progressive pain in the right lower abdominal quadrant.  REFERRED  She was returned for further medical follow up, and a diagnosis of appendicitis complicated by peritonitis was established.  This client recovered fully from all her symptoms following emergency appendectomy surgery  Pancreatitis  Pancreatitis is an inflammation of the pancreas that may result in autodigestion of the pancreas by its own enzymes.  Pancreatitis can be acute or chronic  common is acute pancreatitis.  Pancreatic Carcinoma Clinical Signs and Symptoms of Pancreatic Carcinoma  Epigastric/upper abdominal pain radiating to the back  Low back pain may be the only symptom  Jaundice  Anorexia and weight loss  Light-colored stools  Constipation  Nausea and vomiting  Weakness Inflammatory Bowel Disease  Refers to two inflammatory conditions: o Ulcerative colitis (UC) o Crohn's disease (CD)  Crohn's disease  Crohn's disease inflammatory disease that most commonly attacks the terminal end of the small intestine (ileum) and the colon  Ulcerative Colitis  inflammation and ulceration of the inner lining of the large intestine (colon) and rectum  Ulcerative proctitis: inflammation of rectum  Irritable Bowel Syndrome  common cold of the stomach  functional disorder of motility in the small and large intestines  Slow=> constipation  Fast=> diarrhea  Other descriptive names : spastic colon, irritable colon, nervous indigestion, functional dyspepsia, pylorospasm, spastic colitis, intestinal neuroses, and laxative or cathartic colitis  The typical pain pattern consists of lower left quadrant abdominal pain, constipation, and diarrhea  Abdominal pain or discomfort is relieved by defecation.  Clinical Signs and Symptoms  Painful abdominal cramps  Constipation  Diarrhea  Nausea and vomiting  Anorexia  Flatulence  Foul breath  Colorectal Cancer  Colorectal cancer is the third most commonly diagnosed cancer Acute Colonic Pseudo-obstruction  Acute colonic pseudo-obstruction (Ogilvie's syndrome) is a massive dilation of the cecum and proximal colon in the absence of actual mechanical causes such as colonic obstruction.  most commonly detected in surgical patients after trauma, burns, and GI tract surgery, or in medical patients who have severe metabolic, respiratory and electrolyte disturbances.  Symptoms :  abdominal distention  nausea  vomiting  abdominal pain  absent bowel movements  CASE EXAMPLE  A 67-year-old man is seeing you through home health care for a home program after discharge from the hospital 2 weeks ago for a total hip replacement. His recovery has been slowed by chronic diarrhea. Now what to do???  A 25-year-old woman who is diagnosed as having a sacroiliac pain and joint dysfunction asks you what exercises she can do for constipation. Now what to do???  Guidelines for Immediate Medical Attention  Anytime appendicitis or iliopsoas/obturator abscess is suspected (positive McBurney's test, positive iliopsoas/obturator test, positive test for rebound tenderness)  Anytime the therapist suspects retroperitoneal bleeding from an injured, damaged or ruptured spleen; ectopic pregnancy or history of trauma; positive Kehr's sign THANK YOU! =)