Screening for GI Disease Flashcards
GI most commonly refers to: (8)
- Sternal region
- Shoulder and neck
- Scapular region
- Mid-back
- Low back
- Hip
- Pelvis
- Sacrum
Most common GI disorders that refer to the MSKsystem involve what?
ulceration or infection of the mucosal lining
Signs/Symptoms of GI disease (14)
- 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
Primary GI Visceral Pain Patterns
- what does site of pain generally correspond to?*
- What are pain fibers sensitive to?*
- localized or not?*
- Site of pain generally corresponds to dermatomes
- Pain fibers only sensitive to stretching or tension
- Not well localized
Reasons for abdominal pain (3)
- Inflammation
- Organ distention (Tension pain)
- Necrosis (Ischemic pain)
Primary GI pain patterns (7)
- stomach/duodenum
- liver/gallbladder/common bile duct
- small intestine
- appendix
- esophagus
- pancreas
- large intestine/colon
Primary GI Visceral Pain Patterns descriptors (6)
- Deep aching
- Boring
- Gnawing
- Vague burning
- Deep grinding
- Colicky (comes in waves)
Referred GI Pain Patterns
localized or not?
- 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
Referred GI pain can be perceived in the: (3)
- Shoulder
- Mid-back/scapular region
- Pelvis, flank, low back or sacrum
Referred GI Pain Patterns (10)
- Liver/gallbladder/common bile duct
- appendix
- pancreas
- pancreas
- small intestine
- colon
- esophagus
- stomach/duodenum
- liver/gallbladder/common bile duct
- stomach/duodenum
Dysphagia
if a patient mentions this what should you do?
Sensation that food is catching or sticking in the esophagus
Requires prompt attention from MD
Odynophagia
and 2 things that can cause it
Pain during swallowing
May be caused by
- Esophagitis (caused by GERD, herpes simplex virus or fungus)
- Esophageal spasm
GI Bleeding
what type of MSK pain would occult GI pain present with?
- 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
Clinical Signs and Symptoms of GI
- Coffee ground emesis
- Bloody diarrhea
- Bright red blood
- Melena
- Reddish or mahogany-colored stools
Coffee ground emesis may indicate?
May indicate perforated peptic or duodenal ulcer
Bloody diarrhea present with?
Present with ulcerative colitis
Bright red blood would indicate?
Pathology close to rectum or anus (rectal fissures, hemorrhoids or colorectal cancer)
Melena
- Black, tarry stool
- Result of large quantities of blood in the stool
- Indicates upper GI tract or could be secondary to overuse of NSAIDs
Reddish/mahogany-colored stools
- May occur secondary to food/medications
- May be due to a bleed in the lower GI/colon
Epigastric Pain with Radiation
- 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
Pain associated with gastric ulcers
time frame, how food affects it
May occur within 30-90 mins after eating
Food not likely to relieve pain
Pain associated with duodenal or pyloric ulcers
- May occur 2-4 hours after meals
- Food may relieve symptoms
- May report pain during the night between 12am-3am
Symptoms that are increased or decreased or eliminated by eating food should be what?
screened more thoroughly and referred for further medical evaluation
Early Satiety
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
Constipation
when is constipation a red flag?
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
Changes in bowel habits may occur due to: (constipation)
◦Diet
◦Smoking
◦Side effects of medication
◦Narcotics
◦Aluminum or calcium containing antacids
◦Tricyclic antidepressants
◦Phenothiazines
◦Calcium channel blockers
◦Iron salts
Constipation may be caused by:
◦Acute or chronic diseases of the digestive system
◦Extraabdominal diseases
◦Depression
◦Emotional stress
◦Inactivity
◦Prolonged bed rest
◦Lack of exercise
Diarrhea causes and PT considerations
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
Fecal Incontinence
causes
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
Arthralgia
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
Left shoulder pain
- what might cause it?*
- What is Kehr’s sign?*
- 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
Right shoulder pain
Perforated duodenal or gastric ulcer may refer here
Either shoulder pain
Pancreatic cancer may refer to either shoulder
Obturator or Psoas Abscess
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
Clinical Signs and Symptoms of a Psoas Abcess
◦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
Screening Tests for Psoas Abscess
◦Heel tap
◦Hop test
◦Iliopsoas muscle test
◦Palpate Iliopsoas muscle
Obturator muscle test (for obturator abcess)
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
Other GI related follow-up questions
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?
Potential musculoskeletal sources of abdominal pain
◦Psoas referral
◦Lower thoracic spine
◦Slipping-rib syndrome
◦Myofascial components
Abdominal pain of MSK origin
- Sharp and focal
- Cramping and aching, or deep
- Nausea
Abdominal pain of visceral origin
- Dull, aching, cramping, burning, gnawing, wave-like and poorly localized
- nausea
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?*
Cluster 1:
- Does coughing, sneezing or taking a deep breath make your pain feel worse? (yes)
- Do activities such as bending, sitting, lifting, twisting, or turning over in bed make your pain feel worse? (yes)
- Has there been any change in your bowel habit since the start of your symptoms? (no)
Cluster 2:
- Does eating certain foods make your pain feel worse? (no)
- 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.
Peptic ulcer
- where is the pain?*
- Where is the loss of tissue lining?*
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
Difference between erosions and chronic ulcers
Erosions: Acute lesions that do not extend through the mucosa
Chronic ulcers: Destroys musculature and replaces it with scar tissue
Peptic Ulcer Clinical Signs and Symptoms (2 most important)
Radiating back pain
Right shoulder pain
Other signs and symptoms of peptic Ulcer
- Heartburn
- Night pain (12am-3am)
- Stomach pain
- Lightheadedness/fainting
- Nausea
- Vomiting
- Anorexia
- Weight loss
- Bloody stools
- Black, tarry stools
GI complications of NSAID use
- 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
Risk Factors for NSAID-induced Gastropathy (8)
- Age older than 65 yo
- History of peptic ulcer disease or GI disease
- Smoking, alcohol use
- Oral corticosteroid use
- Anticoagulation or use of anticoagulants
- Renal complications in pt with HTN or CHF
- Use of acid suppressants
- NSAIDs combined with selective serotonin reuptake inhibitors
most important GI complication of NSAID use
New-onset back (thoracic) or shoulder pain
other GI complications of NSAID use
- 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
Inflammatory Bowel Disease
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
Chrohn’s Disease
Inflammatory disease most commonly attacks terminal end of small intestine (ileum) and colon
Occurs more commonly in young adults/adolescents
Ulcerative Colitis
- Inflammation and ulceration of lining of large intestine (colon/rectum)
- Cancer of colon more common in people with UC
IBD and arthritic component
◦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
4 most important clinical signs and symptoms of IBD
- Arthritis
- Migratory arthralgias
- Hip pain (iliopsoas abscess)
- Skin lesions
Other clinical signs and symptoms of IBD
- Diarrhea
- Constipation
- Fever
- Abdominal pain
- Rectal bleeding
- Night sweats
- Decreased appetite, nausea, weight loss
- Uveitis
Colorectal Cancer
- 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
Colorectal Cancer early signs and symptoms (most important)
◦Abdominal, pelvic, back or sacral pain
◦Back pain that radiates down the legs
Colorectal Cancer Early Signs and Symptoms (early and late stage)
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
Pancreatic Carcinoma
70% of pancreatic cancer arise in the head of the gland
20-30% occur in the body and tail
Pancreatic Carcinoma signs and symptoms (most important)
- 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
other signs and symptoms of pancreatic carcinoma
Jaundice
Anorexia and weight loss
Light-colored stools
Constipation
Nausea and vomiting
Weakness
Appendicitis
Inflammation of vermiform appendix
Most common in adolescents and young adults
Serious and usually requires surgery
Most important clinical signs and symptoms of appendicitis
- R lower quadrant/flank pain
- Nausea and vomiting
- Low-grade fever
Appendix: McBurney’s Point
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
Appendix: Rovsing Sign
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
Clues to Screening for GI disease
- 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
Guidelines for Immediate Medical Attention
Suspected appendicitis or iliopsoas/obturator abscess
Suspected retroperitoneal bleeding from injured, damage or ruptured spleen or ectopic pregnancy
Guidelines for Immediate Medical Attention
- 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)
Guidelines for MD referral
- 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)
