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Differential Diagnosis > Screening for GI Disease > Flashcards

Screening for GI Disease Flashcards

1
Q

GI most commonly refers to: (8)

A
  • Sternal region
  • Shoulder and neck
  • Scapular region
  • Mid-back
  • Low back
  • Hip
  • Pelvis
  • Sacrum
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2
Q

Most common GI disorders that refer to the MSKsystem involve what?

A

ulceration or infection of the mucosal lining

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3
Q

Signs/Symptoms of GI disease (14)

A
  • Abdominal pain
  • Dysphagia
  • Odynophagia
  • GI bleeding
  • Epigastric pain
  • Symptoms affected by food
  • Early satiety with weight loss
  • Constipation
  • Diarrhea
  • Fecal incontinence
  • Arthralgia
  • Referred shoulder pain
  • Psoas abscess
  • Tenderness over McBurney’s point
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4
Q

Primary GI Visceral Pain Patterns

  • what does site of pain generally correspond to?*
  • What are pain fibers sensitive to?*
  • localized or not?*
A
  • Site of pain generally corresponds to dermatomes
  • Pain fibers only sensitive to stretching or tension
  • Not well localized
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5
Q

Reasons for abdominal pain (3)

A
  • Inflammation
  • Organ distention (Tension pain)
  • Necrosis (Ischemic pain)
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6
Q

Primary GI pain patterns (7)

A
  1. stomach/duodenum
  2. liver/gallbladder/common bile duct
  3. small intestine
  4. appendix
  5. esophagus
  6. pancreas
  7. large intestine/colon
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7
Q

Primary GI Visceral Pain Patterns descriptors (6)

A
  • Deep aching
  • Boring
  • Gnawing
  • Vague burning
  • Deep grinding
  • Colicky (comes in waves)
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8
Q

Referred GI Pain Patterns

localized or not?

A
  • Often more intense and localized
  • Referred pain to the MSK system can occur in the absence of visceral pain
    • However, visceral pain or other symptoms usually precede referred pain
  • History and presence of signs and symptoms help guide PT
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9
Q

Referred GI pain can be perceived in the: (3)

A
  • Shoulder
  • Mid-back/scapular region
  • Pelvis, flank, low back or sacrum
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10
Q

Referred GI Pain Patterns (10)

A
  1. Liver/gallbladder/common bile duct
  2. appendix
  3. pancreas
  4. pancreas
  5. small intestine
  6. colon
  7. esophagus
  8. stomach/duodenum
  9. liver/gallbladder/common bile duct
  10. stomach/duodenum
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11
Q

Dysphagia

if a patient mentions this what should you do?

A

Sensation that food is catching or sticking in the esophagus

Requires prompt attention from MD

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12
Q

Odynophagia

and 2 things that can cause it

A

Pain during swallowing

May be caused by

  • Esophagitis (caused by GERD, herpes simplex virus or fungus)
  • Esophageal spasm
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13
Q

GI Bleeding

what type of MSK pain would occult GI pain present with?

A
  • Occult GI bleeding may appear as mid-thoracic pain
    • With radiation of pain to R upper quadrant
  • Ask about presence of blood in vomit or stool
  • MD should evaluate any type of bleeding
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14
Q

Clinical Signs and Symptoms of GI

A
  • Coffee ground emesis
  • Bloody diarrhea
  • Bright red blood
  • Melena
  • Reddish or mahogany-colored stools
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15
Q

Coffee ground emesis may indicate?

A

May indicate perforated peptic or duodenal ulcer

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16
Q

Bloody diarrhea present with?

A

Present with ulcerative colitis

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17
Q

Bright red blood would indicate?

A

Pathology close to rectum or anus (rectal fissures, hemorrhoids or colorectal cancer)

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18
Q

Melena

A
  • Black, tarry stool
  • Result of large quantities of blood in the stool
  • Indicates upper GI tract or could be secondary to overuse of NSAIDs
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19
Q

Reddish/mahogany-colored stools

A
  • May occur secondary to food/medications
  • May be due to a bleed in the lower GI/colon
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20
Q

Epigastric Pain with Radiation

A
  • Intense or sharp pain behind breastbone with radiation to back
  • May occur secondary to long-standing ulcers
  • Heartburn
    • Begins at xiphoid process and radiates up toward neck and throat
    • Bitter or sour taste, abdominal bloating, gas or general abdominal discomfort

MD must evaluate and diagnose cause of epigastric pain/heartburn

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21
Q

Pain associated with gastric ulcers

time frame, how food affects it

A

May occur within 30-90 mins after eating

Food not likely to relieve pain

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22
Q

Pain associated with duodenal or pyloric ulcers

A
  • May occur 2-4 hours after meals
  • Food may relieve symptoms
  • May report pain during the night between 12am-3am
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23
Q

Symptoms that are increased or decreased or eliminated by eating food should be what?

A

screened more thoroughly and referred for further medical evaluation

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24
Q

Early Satiety

A

Feel hungry but gets the sensation of fullness after 1-2 bites

Can be a symptom of

  • Obstruction
  • Stomach cancer
  • Gastroparesis
  • Peptic ulcer disease
  • Tumor
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25
Q

Constipation

when is constipation a red flag?

A

Prolonged retention of fecal content in the GI tract due to decreased motility of colon

RED FLAGS: Unexplained constipation with sudden and unaccountable changes in bowel habits or blood in stool

PT related considerations:

  • Severe constipation can cause back pain
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26
Q

Changes in bowel habits may occur due to: (constipation)

A

◦Diet

◦Smoking

◦Side effects of medication

◦Narcotics

◦Aluminum or calcium containing antacids

◦Tricyclic antidepressants

◦Phenothiazines

◦Calcium channel blockers

◦Iron salts

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27
Q

Constipation may be caused by:

A

◦Acute or chronic diseases of the digestive system

◦Extraabdominal diseases

◦Depression

◦Emotional stress

◦Inactivity

◦Prolonged bed rest

◦Lack of exercise

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28
Q

Diarrhea causes and PT considerations

A

May be accompanied by urgency, discomfort and fecal incontinence

Causes:

  • Food
  • Alcohol
  • Use of laxatives
  • Medication side effects
  • Travel

PT Considerations:

  • C. diff
  • Creatine use
  • Laxative abuse
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29
Q

Fecal Incontinence

causes

A

Inability to control evacuation of stool

Associated with a sense of urgency, diarrhea and abdominal cramping

Causes

  • Partial obstruction of rectum
  • Colitis
  • Radiation therapy
  • Anal distortion secondary to traumatic childbirth
  • Hemorrhoids
  • Hemorrhoidal surgery
30
Q

Arthralgia

A

Many GI conditions have an arthritic component

  • Ie Crohn’s disease often accompanied by rheumatic manifestations (as well as arthritic component)

Arthralgia associated with GI infection is usually (known as reactive arthritis)

  • Asymmetric
  • Migratory (jumps around)
  • Affecting only 1-2 joints
31
Q

Left shoulder pain

  • what might cause it?*
  • What is Kehr’s sign?*
A
  • May be a result of free air following laproscopic surgery or blood in the abdominal cavity (usually from ruptured spleen or retroperitoneal bleeding)
  • Screen for precipitating trauma/injury (ie sharp blow, fall MVA)
  • Kehr’s sign: pain in shoulder with pressure placed on left upper abdomen
32
Q

Right shoulder pain

A

Perforated duodenal or gastric ulcer may refer here

33
Q

Either shoulder pain

A

Pancreatic cancer may refer to either shoulder

34
Q

Obturator or Psoas Abscess

A

Abscess of these muscles may cause lower abdominal pain

Inflammation or infection may spread to these muscles from adjacent structures secondary to no protective barrier

35
Q

Clinical Signs and Symptoms of a Psoas Abcess

A

◦Fever

◦Night sweats

◦Abdominal pain

◦Loss of appetite or other GI upset

◦Back, pelvic, abdominal, hip and/or knee pain

◦Antalgic gait

◦Palpable, tender mass

36
Q

Screening Tests for Psoas Abscess

A

◦Heel tap

◦Hop test

◦Iliopsoas muscle test

◦Palpate Iliopsoas muscle

37
Q

Obturator muscle test (for obturator abcess)

A

Positive test for muscle affected by peritoneal infection or inflammation from a perforated appendix reproduces right lower quadrant abdominal or pelvic pain with testing of the muscle

38
Q

Other GI related follow-up questions

A

Do you notice a change in symptoms after eating?

Do you notice a change in symptoms after a bowel movement or after passing gas?

Do you have abdominal pain at the same time as your back pain?

39
Q

Potential musculoskeletal sources of abdominal pain

A

◦Psoas referral

◦Lower thoracic spine

◦Slipping-rib syndrome

◦Myofascial components

40
Q

Abdominal pain of MSK origin

A
  • Sharp and focal
  • Cramping and aching, or deep
  • Nausea
41
Q

Abdominal pain of visceral origin

A
  • Dull, aching, cramping, burning, gnawing, wave-like and poorly localized
  • nausea
42
Q

Clusters to differentiate MSK pain from visceral abdominal pain

  • What is included in cluster 1 and 2?*
  • What makes MSK origin a moderate probability? A strong probability?*
A

Cluster 1:

  1. Does coughing, sneezing or taking a deep breath make your pain feel worse? (yes)
  2. Do activities such as bending, sitting, lifting, twisting, or turning over in bed make your pain feel worse? (yes)
  3. Has there been any change in your bowel habit since the start of your symptoms? (no)

Cluster 2:

  1. Does eating certain foods make your pain feel worse? (no)
  2. Has your weight changed since your symptoms started? (no)

Answering yes to either of the first 2 questions and no to the third question in cluster 1 results in a moderate probability that the patient’s abdominal complaints are of MSK origin. The probability increases to strong if both questions in cluster 2 are answered with a no.

43
Q

Peptic ulcer

  • where is the pain?*
  • Where is the loss of tissue lining?*
A

Loss of tissue lining lower esophagus, stomach and duodenum

Can cause shoulder pain (usually R) or back

Caused by

  • infection with H. pylori
  • Chronic NSAID use
44
Q

Difference between erosions and chronic ulcers

A

Erosions: Acute lesions that do not extend through the mucosa

Chronic ulcers: Destroys musculature and replaces it with scar tissue

45
Q

Peptic Ulcer Clinical Signs and Symptoms (2 most important)

A

Radiating back pain

Right shoulder pain

46
Q

Other signs and symptoms of peptic Ulcer

A
  • Heartburn
  • Night pain (12am-3am)
  • Stomach pain
  • Lightheadedness/fainting
  • Nausea
  • Vomiting
  • Anorexia
  • Weight loss
  • Bloody stools
  • Black, tarry stools
47
Q

GI complications of NSAID use

A
  • Most obvious clinical negative effect is on the gastroduodenal mucosa
  • Range from subclinical erosion of mucosa to ulceration with life-threatening bleeding and perforation
  • Responsible for 40% of hospital admissions among pts with arthritis

NSAID-induced GI bleeding is major cause of morbidity and mortality among older population

48
Q

Risk Factors for NSAID-induced Gastropathy (8)

A
  1. Age older than 65 yo
  2. History of peptic ulcer disease or GI disease
  3. Smoking, alcohol use
  4. Oral corticosteroid use
  5. Anticoagulation or use of anticoagulants
  6. Renal complications in pt with HTN or CHF
  7. Use of acid suppressants
  8. NSAIDs combined with selective serotonin reuptake inhibitors
49
Q

most important GI complication of NSAID use

A

New-onset back (thoracic) or shoulder pain

50
Q

other GI complications of NSAID use

A
  • Asymptomatic
  • Stomach upset/pain
  • Indigestion, heartburn
  • Skin reactions
  • Increased blood pressure
  • Melena
  • Tinnitus
  • CNS changes
    • Headache
    • Depression
    • Confusion (older pts)
    • Memory loss (older pts)
    • Mood changes
  • Renal involvement
    • Muscle weakness
    • Unusual fatigue
    • Restless legs syndrome
    • Polyuria
    • Nocturia
    • Pruritus
51
Q

Inflammatory Bowel Disease

A

Refers to Crohn’s disease and Ulcerative colitis

Disorders of unknown etiology involving genetic and immunologic influences on GI tract

Both chronic, medically incurable conditions

Nutritional deficiencies are most common complications of IBD

Skin lesions may occur

  • Erythema nodosum
  • Pyoderma
52
Q

Chrohn’s Disease

A

Inflammatory disease most commonly attacks terminal end of small intestine (ileum) and colon

Occurs more commonly in young adults/adolescents

53
Q

Ulcerative Colitis

A
  • Inflammation and ulceration of lining of large intestine (colon/rectum)
  • Cancer of colon more common in people with UC
54
Q

IBD and arthritic component

A

◦Ulcerative colitis and Crohn’s disease can be accompanied by arthritic component

◦Skin rash affects 25% of pts with IBD

◦Joint problems usually are responsive to treatment of IBD but do on occasion require separate management

55
Q

4 most important clinical signs and symptoms of IBD

A
  • Arthritis
  • Migratory arthralgias
  • Hip pain (iliopsoas abscess)
  • Skin lesions
56
Q

Other clinical signs and symptoms of IBD

A
  • Diarrhea
  • Constipation
  • Fever
  • Abdominal pain
  • Rectal bleeding
  • Night sweats
  • Decreased appetite, nausea, weight loss
  • Uveitis
57
Q

Colorectal Cancer

A
  • 3rd leading cause of cancer deaths
  • Incidence increases with age, beginning around 40
  • Screening can significantly reduce mortality
  • High-risk groups
    • Previous history of chronic IBD, adenomatous polyps and hereditary colon cancer
58
Q

Colorectal Cancer early signs and symptoms (most important)

A

◦Abdominal, pelvic, back or sacral pain

◦Back pain that radiates down the legs

59
Q

Colorectal Cancer Early Signs and Symptoms (early and late stage)

A

Early Stage:

  • Changes in bowel patterns
  • Rectal bleeding, hemorrhoids

Late Stage:

  • Constipation progressing to obstipation
  • Diarrhea with copious amounts of mucus
  • Nausea, vomiting
  • Abdominal distention
  • Weight loss
  • Fatigue and dyspnea
  • Fever
60
Q

Pancreatic Carcinoma

A

70% of pancreatic cancer arise in the head of the gland

20-30% occur in the body and tail

61
Q

Pancreatic Carcinoma signs and symptoms (most important)

A
  • Epigastric/upper abdominal pain radiating to the back
  • Lower back pain may be only symptom
  • Pain is worse with walking and lying supine and relieved by sitting and leaning forward
62
Q

other signs and symptoms of pancreatic carcinoma

A

Jaundice

Anorexia and weight loss

Light-colored stools

Constipation

Nausea and vomiting

Weakness

63
Q

Appendicitis

A

Inflammation of vermiform appendix

Most common in adolescents and young adults

Serious and usually requires surgery

64
Q

Most important clinical signs and symptoms of appendicitis

A
  • R lower quadrant/flank pain
  • Nausea and vomiting
  • Low-grade fever
65
Q

Appendix: McBurney’s Point

A

Procedure:

◦Patient Position: Supine

◦Examiner Position: Standing to right side of pt.

◦Deep palpation at a point 1/3 – 1/2 distance from the ASIS to the umbilicus

◦Quickly release and assess for rebound tenderness

Abnormal Findings: Tenderness

66
Q

Appendix: Rovsing Sign

A

Procedure:

◦Patient Position: Supine

◦Examiner Position: Standing to right side of pt.

◦Rebound tenderness testing administered at the lower left quadrant

Abnormal Findings: right lower quadrant tenderness with remote rebound testing at

67
Q

Clues to Screening for GI disease

A
  • Previous history of NSAID-induced GI bleeding
  • Symptoms increase within 2 hours after taking NSAIDs or other meds
  • Symptoms affected by food
  • Back pain and abdominal pain at the same level (esp in presence of constitutional symptoms)
  • Shoulder, back, pelvic or sacral pain
    • Of unknown origin (esp with hx of cancer)
    • Affected by food, milk, antacids or vomiting
    • Accompanied by constitutional symptoms
  • Back, pelvic or sacral pain relieved/reduced by bowel movement
  • Low back pain accompanied by constipation
  • Joint pain with arthralgias preceded by skin rash
68
Q

Guidelines for Immediate Medical Attention

A

Suspected appendicitis or iliopsoas/obturator abscess

Suspected retroperitoneal bleeding from injured, damage or ruptured spleen or ectopic pregnancy

69
Q

Guidelines for Immediate Medical Attention

A
  • Pts who chronically rely on laxatives
  • Joint involvement accompanied by skin or eye lesions if MD is unaware
  • History of NSAID use with back or shoulder pain accompanied by signs and symptoms of peptic ulcer
  • Back pain associated with meals or relieved by a bowel movement (esp if accompanied by rectal bleeding)
  • Back pain of unknown cause that doesn’t fit musculoskeletal pattern (esp with history of cancer)
70
Q

Guidelines for MD referral

A
  • Pts who chronically rely on laxatives
  • Joint involvement accompanied by skin or eye lesions if MD is unaware
  • History of NSAID use with back or shoulder pain accompanied by signs and symptoms of peptic ulcer
  • Back pain associated with meals or relieved by a bowel movement (esp if accompanied by rectal bleeding)
  • Back pain of unknown cause that doesn’t fit musculoskeletal pattern (esp with history of cancer)

Differential Diagnosis (14 decks)

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