GI Disorders and Pelvic PT Considerations Flashcards
Upper GI
Difficulty swallowing
Nausea/vomit
Indigestion
Acid reflux
Lower GI
Severe pain in lower quadrant
Loss of bowel control
Change in stools
Systemic
Loss of appetite Unexplained weight loss Sever bloating Sudden loss of b/b control Night pain Night sweats
Cardiac
Chest tightness
Thoracic pain
Anatomy - rectum - function and from where to where
Storage
15-20 cm long
Starts at S3 at rectosigmoid junction and ends just below tip of coccyx
Anatomy - rectum - Ampula is what
Bottom 2/3 of rectum
Most distensible
Anatomy - rectum - what type of mm
smooth muscle
Anatomy - rectum - Sensation
Distension is sensed due to fascia surrounding rectum or receptors in rectal lining
If less than 15cm = gas
If more than 15 cm = stool
Anatomy - anus
3-4 cm long starting at levator ani mm
2/5 cm below coccyx
Pectinate line - 1.5-2 cm above anal verge
Anatomy - Anorectal mm
Muscular ring comprised of external anal sphincter and puborectalis
They contract simultaneously to kink off anorectal junction and aid in fecal continence
Puborectalis maintains anorectal angle at
90 degrees
Greater than 100 = fecal incontinence
Less than 80 or 90 = constipation
Anatomy - vascular supply - arteries
Superior, medial, inferior rectal arteries
Superior = above pectineal line
Inferior = below
Anatomy - Vascular supply - veins
Superior, medial, inferior rectal veins
Anatomy - vascular supply - Anal cushions
3 submucosal vascular plexes formed from anastamosis of veins
Hemorrhoids:
- internal - usually not P
- external - generally P
Anatomy - nerve supply
Autonomic
Spinal
Somatic
Anatomy - nerve supply - Autonomic
(visceral) Sensitive to stretch Above the pectineal line Sympathetics - L1-L3 Parasymp - S2-S4
Anatomy - nerve supply - spinal
S1, S2, S3
Supply striated muscle, travel in pudendal nerve
Anatomy - nerve supply - somatic
Pudendal nerve
S2-S4
Pain temp touch sensation
Below pectineal line
Anatomy - nerve supply - inferior rectal nerve
Sensory and motor below dentate line including EAS
Anatomy - nerve supply - perineal
Sensory and motor to perianal region
Physiology of defecation - define it
Final act of digestion with expulsion of solid, semi solid, or liquid material through anus
Defecation - normal
2-3 times a day to 2-3 times a week
Defecation - transit time
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
Physiology of defecation - Colonic function “storage and mixing” - Ascending
Stores chyme
Mixes with mucus and bacteria to form feces
Physiology of defecation - Colonic function “storage and mixing” - Transverse
Contents change from liquid to semi solid
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
Physiology of defecation - Colonic function “storage and mixing” - Descending
Transports stool to rectosigmoid colon for storage
Motility is irregular with bursts of propogated contractions
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
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
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
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
Bristol Stool Chart
Types 1-3 are said to be indicators of constipation
Types 1 -7
Bristol Stool chart - type 1
Separate hard lumps, like nuts
Hard to pass
Bristol Stool Chart - type 2
sausage shaped but lumpy
Bristol Stool Chart - type 3
like a sausage but with cracks on its surface
Bristol Stool Chart - type 4
like a sausage or snake, smooth and soft
Bristol Stool Chart - type 5
soft blobs with clean cut edges (passed easily)
Bristol Stool Chart - type 6
fluffy pieces with ragged edges
A mushy stool
Bristol Stool Chart - type 7
watery, no solid pieces
entirely liquid
Conditions with constipation - colonic disorders
IBS Cancer Inflammation (divertic, crohns) Chronic laxative use Pelvic mm injury (prolapse) Anal disease
Conditions with constipation - Hormonal
Pregnancy
Diabetes
Abnormalities of thyroid or parathyroid
Conditions with constipation - Neurological
MS
Stroke
SCI
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
Other causes of constipation
Hydration
Diet (high process, sugar, low fiber)
Inactivity
PT eval for bowel disorders
Assess for QOL impact
Constipation scoring system (good questions but not good sensitivity to track overtime)
Subjective hx
Screening of urological and gynecological systems and surgical hx
Bowel screening
Exercise, sleep, stress
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
PT interventions for constipation
Pelvic floor mm rehab Posture, exercise, manual Relaxation training, stress reduction Bowel mechanics Manual perineal support (esp with prolapse)
Constipation treatment
Pelvic floor retraining
Biofeedback
Bowel retraining
Diet/supplements
Constipation treatment - pelvic floor retraining
Goal of eccentric length of abdominals and PFM
Big hard belly
Sensory training
Constipation treatment - bowel retraining
sit on toilet 10-15 min after eating
toileting posture
Constipation treatment - diet/supplements
FIber
Mg citrate
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
Obstructed defecation - consists of
Anismus sphincter dyssynergia non relaxing puborectalis dyssnergic defecation PFM dyssynergia
Obstructed defecation - symptoms
Small, skinny stools
Pressure in pelvic floor
Pain with BM/coccydynia/dyspareunia
Leaking feces or mucus
Obstructed defecation - treatment
Focus on PFM dysfunction with EMG feedback to dec paradoxical dyssynergy
Consider diet, fiber, bx program if stool is hard
Dyssynergic defecation - is what
Difficulty or inability to expel stool
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
Dyssynergic defecation - present with
Impaired sensory awareness of rectal filling
Can be present with slow transit or IBS-C
May be a learned bx
Dyssynergic defecation - also labeled as
Obstructive defecation
Anismus
Pelvic floor dyssynergia
Outlet obstruction
Fecal incontinence etiology
Impaired anal closure mechanism - imapired triad: 1 exertnal anal sphinter 2 internal anal sphincter (most important) 3 puborectalis
Fecal incontinence - consistency of stool
liquid or solid
Fecal incontinence - Causes
Constipation
Anxiety/stress
Poor diet
Fecal and anal incontinence - Internal anal sphincter
Smooth mm
has 70-80% contractility for resting tone
Fecal and anal incontinence - external anal sphincter
20% resting tone
Striated mm has 20% contractility for resting tone
Fecal and anal incontinence - Continence is maintained by
striated muscles and increasing their strength
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
Medicare Reimbursement for biofeedback
Yes for urinary and fecal incontinence
But not for down regulation or relaxation
Irritable bowel syndrome is what
Functional disorder
No structural, inflammatory, or biomechanical abnormalities
Brain-gut connection and immune system theories
IBS - diagnosis based on
symptoms, no definitive tests
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
IBS - symptoms
Abdominal pain, bloating, gas
Change in bowel habits
IBS - Rome III criteria
IBS D
IBS C
IBS M
IBS U
IBS - Rome III criteria - D =
diarrhea predominent
IBS - Rome III criteria - C =
Constipation predominent
IBS - Rome III criteria - M
Mixed diarrhea and constipation
IBS - Rome III criteria - U
Unsubtyped - insufficient abnormality of consistency of stool to meet other types
IBS - Rome III criteria - changing subtypes
In one year 75% of pts changed subtypes and 29% change between C and D
IBS prevalence
60-65% F
35-40% M
Onset between 20 and 40
Overall 10-15% population
IBS tx
Relieving symptoms Pharm Psychotherapy Dietician PT
IBS - PT tx
Pain mngmnt soft tissue impairments muscular imbalance PFM dyscuntion Biofeedback Breathing Exercise (aerobic and trunk stab) Relax/stree reduction
Colorectal CA - epidemilogy
3rd leading among american M and W
3rd leading cause of cancer death
On decline though because of screening
Colorectal CA - risk factors
Cause unknown but hought to be influenced by familial and environment
Colorectal CA - symptoms
Few early on Frequently asymp until metastasis Blood loss from colon Abdominal pain/bloating Weight loss Change in bowel habits
COlorectal CA - complications
Intestinal obstruction GI bleeding Perforation Anemia Ascites Metastasis to liver, lungs, bone brain
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%
Colon CA - tx
Surgery
Chemo
Radiation
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
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
