GI Disorders and Pelvic PT Considerations Flashcards
1
Q
Upper GI
A
Difficulty swallowing
Nausea/vomit
Indigestion
Acid reflux
2
Q
Lower GI
A
Severe pain in lower quadrant
Loss of bowel control
Change in stools
3
Q
Systemic
A
Loss of appetite Unexplained weight loss Sever bloating Sudden loss of b/b control Night pain Night sweats
4
Q
Cardiac
A
Chest tightness
Thoracic pain
5
Q
Anatomy - rectum - function and from where to where
A
Storage
15-20 cm long
Starts at S3 at rectosigmoid junction and ends just below tip of coccyx
6
Q
Anatomy - rectum - Ampula is what
A
Bottom 2/3 of rectum
Most distensible
7
Q
Anatomy - rectum - what type of mm
A
smooth muscle
8
Q
Anatomy - rectum - Sensation
A
Distension is sensed due to fascia surrounding rectum or receptors in rectal lining
If less than 15cm = gas
If more than 15 cm = stool
9
Q
Anatomy - anus
A
3-4 cm long starting at levator ani mm
2/5 cm below coccyx
Pectinate line - 1.5-2 cm above anal verge
10
Q
Anatomy - Anorectal mm
A
Muscular ring comprised of external anal sphincter and puborectalis
They contract simultaneously to kink off anorectal junction and aid in fecal continence
11
Q
Puborectalis maintains anorectal angle at
A
90 degrees
Greater than 100 = fecal incontinence
Less than 80 or 90 = constipation
12
Q
Anatomy - vascular supply - arteries
A
Superior, medial, inferior rectal arteries
Superior = above pectineal line
Inferior = below
13
Q
Anatomy - Vascular supply - veins
A
Superior, medial, inferior rectal veins
14
Q
Anatomy - vascular supply - Anal cushions
A
3 submucosal vascular plexes formed from anastamosis of veins
Hemorrhoids:
- internal - usually not P
- external - generally P
15
Q
Anatomy - nerve supply
A
Autonomic
Spinal
Somatic
16
Q
Anatomy - nerve supply - Autonomic
A
(visceral) Sensitive to stretch Above the pectineal line Sympathetics - L1-L3 Parasymp - S2-S4
17
Q
Anatomy - nerve supply - spinal
A
S1, S2, S3
Supply striated muscle, travel in pudendal nerve
18
Q
Anatomy - nerve supply - somatic
A
Pudendal nerve
S2-S4
Pain temp touch sensation
Below pectineal line
19
Q
Anatomy - nerve supply - inferior rectal nerve
A
Sensory and motor below dentate line including EAS
20
Q
Anatomy - nerve supply - perineal
A
Sensory and motor to perianal region
21
Q
Physiology of defecation - define it
A
Final act of digestion with expulsion of solid, semi solid, or liquid material through anus
22
Q
Defecation - normal
A
2-3 times a day to 2-3 times a week
23
Q
Defecation - transit time
A
Variable - ranges from 1-4 days
50% of stamch is emptied in 2.5-3 hrs
Small intestine - 4 to 6 hrs
Colonic transit - 24 to 72 hours
24
Q
Physiology of defecation - Colonic function “storage and mixing” - Ascending
A
Stores chyme
Mixes with mucus and bacteria to form feces
25
Physiology of defecation - Colonic function "storage and mixing" - Transverse
Contents change from liquid to semi solid
26
Physiology of defecation - Colonic function "storage and mixing" - transverse to descending
Absorption of water and electrolytes
| Bacteria work to decompose fiber which nourishes the lining of the colon
27
Physiology of defecation - Colonic function "storage and mixing" - Descending
Transports stool to rectosigmoid colon for storage
| Motility is irregular with bursts of propogated contractions
28
Physiology of defection - Rectal function
Distends from filling with stool
Stretch receptors signal sensory receptors for urge to defecate
Rectal compliance allows stretch receptors to initiate urge and peristalsis
Rectoanal inhibitory reflex and rectoanal excitatory reflex cause IAS to relax and EAS to contract
Respond to "call to stool"
EAS relaxation for passage of stool
Slight inc in abdominal pressure
Anorectal angle decrease and sphincters return to normal resting tone
29
Evacuation dysfunction defined by
frequency (goal 1/day)
Stool consistency and shape
Effort and time needed to evacuate (should be less than 1 min)
Feelings of incomplete emptying
Colon transit (slow/fast)
Colonic inertia and megacolon, megarectum
Sphincter/PFM function or dyssnergia
30
Constipation - Rome III criteria
Symptom based diagnosis
Must have at least 2 of the following symptoms for at least 6 months prior to diagnosis:
Defecation less than 3/wk
Straining or lumpy hard stools 25% of time (type 1 or 2)
Sensation of incomplete evacuation
31
Constipation - prevalence
```
Most common GI complaint in US
Affects 1 in 6 individuals
2.5 million visits a year
Women 2-3x more than men
Only 22% discuss with doc
$400 million spent on laxatives a year
```
32
Bristol Stool Chart
Types 1-3 are said to be indicators of constipation
| Types 1 -7
33
Bristol Stool chart - type 1
Separate hard lumps, like nuts
| Hard to pass
34
Bristol Stool Chart - type 2
sausage shaped but lumpy
35
Bristol Stool Chart - type 3
like a sausage but with cracks on its surface
36
Bristol Stool Chart - type 4
like a sausage or snake, smooth and soft
37
Bristol Stool Chart - type 5
soft blobs with clean cut edges (passed easily)
38
Bristol Stool Chart - type 6
fluffy pieces with ragged edges
| A mushy stool
39
Bristol Stool Chart - type 7
watery, no solid pieces
| entirely liquid
40
Conditions with constipation - colonic disorders
```
IBS
Cancer
Inflammation (divertic, crohns)
Chronic laxative use
Pelvic mm injury (prolapse)
Anal disease
```
41
Conditions with constipation - Hormonal
Pregnancy
Diabetes
Abnormalities of thyroid or parathyroid
42
Conditions with constipation - Neurological
MS
Stroke
SCI
43
Meds that cause constipation
```
Antacids that contain Al or Ca
Iron supplements
Opiate pain meds
Antidepressants
Antiparkinson drugs
Meds for BP
Diuretics (K loss)
Nasal decongestants
Antihistamines
```
44
Other causes of constipation
Hydration
Diet (high process, sugar, low fiber)
Inactivity
45
PT eval for bowel disorders
Assess for QOL impact
| Constipation scoring system (good questions but not good sensitivity to track overtime)
46
Subjective hx
Screening of urological and gynecological systems and surgical hx
Bowel screening
Exercise, sleep, stress
47
Eval with pelvic PT
```
Postural and functional assess
SI, coccyx, low back, hip
Strength and core stabilization
Breathing
External and internal vaginal and rectal exams
```
48
PT interventions for constipation
```
Pelvic floor mm rehab
Posture, exercise, manual
Relaxation training, stress reduction
Bowel mechanics
Manual perineal support (esp with prolapse)
```
49
Constipation treatment
Pelvic floor retraining
Biofeedback
Bowel retraining
Diet/supplements
50
Constipation treatment - pelvic floor retraining
Goal of eccentric length of abdominals and PFM
Big hard belly
Sensory training
51
Constipation treatment - bowel retraining
sit on toilet 10-15 min after eating
| toileting posture
52
Constipation treatment - diet/supplements
FIber
| Mg citrate
53
Obstructed defecation - what is it
Incoordination with paradoxical contractions
PFM and EAS inappropriately contract with vasalva for defecation
Failure of anorectal angel to inc with bearing down
Pudendal nerve dysfunction
54
Obstructed defecation - consists of
```
Anismus
sphincter dyssynergia
non relaxing puborectalis
dyssnergic defecation
PFM dyssynergia
```
55
Obstructed defecation - symptoms
Small, skinny stools
Pressure in pelvic floor
Pain with BM/coccydynia/dyspareunia
Leaking feces or mucus
56
Obstructed defecation - treatment
Focus on PFM dysfunction with EMG feedback to dec paradoxical dyssynergy
Consider diet, fiber, bx program if stool is hard
57
Dyssynergic defecation - is what
Difficulty or inability to expel stool
58
Dyssynergic defecation - Failure to
Adequately relax the puborectalis (which inc the angle btw rectal vault and anal canal)
Coordinate with abdominal mm contraction to inc intraabdominal pressure
59
Dyssynergic defecation - present with
Impaired sensory awareness of rectal filling
Can be present with slow transit or IBS-C
May be a learned bx
60
Dyssynergic defecation - also labeled as
Obstructive defecation
Anismus
Pelvic floor dyssynergia
Outlet obstruction
61
Fecal incontinence etiology
```
Impaired anal closure mechanism
- imapired triad:
1 exertnal anal sphinter
2 internal anal sphincter (most important)
3 puborectalis
```
62
Fecal incontinence - consistency of stool
liquid or solid
63
Fecal incontinence - Causes
Constipation
Anxiety/stress
Poor diet
64
Fecal and anal incontinence - Internal anal sphincter
Smooth mm
| has 70-80% contractility for resting tone
65
Fecal and anal incontinence - external anal sphincter
20% resting tone
| Striated mm has 20% contractility for resting tone
66
Fecal and anal incontinence - Continence is maintained by
striated muscles and increasing their strength
67
PT tx of fecal incontinence
```
Diet considerations
PFM activation with estim
Strengthen core and PFM
Sensory retrain with balloon
Bowel diary/train
Improve stool consistency - diet, meds, ANS
```
68
Medicare Reimbursement for biofeedback
Yes for urinary and fecal incontinence
| But not for down regulation or relaxation
69
Irritable bowel syndrome is what
Functional disorder
No structural, inflammatory, or biomechanical abnormalities
Brain-gut connection and immune system theories
70
IBS - diagnosis based on
symptoms, no definitive tests
71
IBS - diagnosis - symptoms used
Recurrent abdominal pain/discomfort at least 3 days/month during previous 3 months
Relieved by defecation
Onset associated with change in stool freq
Onset associated with change in stool form/appearance
72
IBS - symptoms
Abdominal pain, bloating, gas
| Change in bowel habits
73
IBS - Rome III criteria
IBS D
IBS C
IBS M
IBS U
74
IBS - Rome III criteria - D =
diarrhea predominent
75
IBS - Rome III criteria - C =
Constipation predominent
76
IBS - Rome III criteria - M
Mixed diarrhea and constipation
77
IBS - Rome III criteria - U
Unsubtyped - insufficient abnormality of consistency of stool to meet other types
78
IBS - Rome III criteria - changing subtypes
In one year 75% of pts changed subtypes and 29% change between C and D
79
IBS prevalence
60-65% F
35-40% M
Onset between 20 and 40
Overall 10-15% population
80
IBS tx
```
Relieving symptoms
Pharm
Psychotherapy
Dietician
PT
```
81
IBS - PT tx
```
Pain mngmnt
soft tissue impairments
muscular imbalance
PFM dyscuntion
Biofeedback
Breathing
Exercise (aerobic and trunk stab)
Relax/stree reduction
```
82
Colorectal CA - epidemilogy
3rd leading among american M and W
3rd leading cause of cancer death
On decline though because of screening
83
Colorectal CA - risk factors
Cause unknown but hought to be influenced by familial and environment
84
Colorectal CA - symptoms
```
Few early on
Frequently asymp until metastasis
Blood loss from colon
Abdominal pain/bloating
Weight loss
Change in bowel habits
```
85
COlorectal CA - complications
```
Intestinal obstruction
GI bleeding
Perforation
Anemia
Ascites
Metastasis to liver, lungs, bone brain
```
86
COlon CA - prevention
Screening is effective with colonoscopy 90%
Performed at age 50 and ever 10 years after if normal
Dets high in fruits, vegt, and fiber
Mod activity dec risk by 50%
87
Colon CA - tx
Surgery
Chemo
Radiation
88
COlon CA - PT considerations
```
Impaired posture from abdominal scars
Lymphedema
Strengthenign based on deconditioned status
Movement to stimulate bowels
PFM retrainign to relearn bowel control
Complications from radiation - dilators
```
89
Rehab for bowel disorders
```
Education
Normal fluid intake needs
Dietary counseling
Bwel management with gastocolic reflex
Attn to toilet postures to inc puborectalis angle
Biofeedback
Urge control
Cog bx therapy
Exercise for post evacuation seepage - hip isometric ER with EAS contraction
```
