Gastrointestinal Tract
Jackson Faught Grace Laferriere Ana Mari Parker Kayla Smith Signs and Symptoms1 ● Abdominal pain ● Excessive belching ● Achalasia (inability for esophageal ● Excessive flatulence muscles to relax) ● Food intolerance ● Appetite changes/disordered ● GI bleeding (in urine or stool) eating habits ● Heartburn ● Changes in bowel movements ● Hemorrhoids (control, color, size, habits) ● Jaundice ● Constipation ● Nausea ● Diarrhea ● Vomiting ● Dysphagia (difficulty swallowing) ● Weight loss or gain https://media.lanecc.edu/users/howardc/PTA103/103GU_GIConditions/103GU_GIConditions2_print.html Important Questions ● Have you had any stomach ● Can you pinpoint what issues lately? caused your pain? ○ Trouble going to the ● Have you found anything that bathroom or going more seems to help? than normal? ● Has it been bad enough to ○ Any heartburn? prevent you from doing things ○ Any stomach pain? you want to? ○ Any changes in your appetite or your diet? ● Is your PCP aware of the ○ Any unexplained weight problem? loss/gain ○ Any nausea or vomiting? Rationale for Questions1 1. A no may indicate serious pathology, including 1. Was your weight loss cancer. Follow up about timeline and cancer history intentional? 2. Follow up with questions regarding food 2. Is your heartburn worsening tolerance and bowel movements to determine in intensity or frequency? need for referral. 3. We can use this question to understand when 3. Have you found anything that the best time to see our patient would be if seems to help? symptoms were predictable, to make the patient comfortable, and unrelenting symptoms indicate 4. Is your PCP aware of the pathology. problem? 4. If PCP is aware, we can consult with them to better understand our patient and how to proceed with care. If not, refer if symptoms are severe enough.
- Pain of Visceral Structures1,2,3 ● Dull, nauseating, aching, squeezing, gnawing, burning, or cramping pain ● Caused by contraction, distention,or inflammation ● May lead to increased firing of autonomic nerves ● Pain may be related to: ○ embryonic development location ○ similar nerve innervations ○ somatic areas by compression of nerves that innervate neighboring structures Referral Patterns2,3
● Pancreas: below the xiphoid process in the epigastric region, compression of diaphragm can cause pain in left shoulder (shared innervation-C3,C4,C5) ● Esophagus: midline of sternum, ulcer causes pain with swallowing and lying down ● Stomach: LUQ
● Small Intestine: umbilical region http://www.maropice.com/human-anatomy-liver/human-anatomy-liver-awesome-tag-liver-gallbladder-pain-relief-archives-human/ ● Large Intestine: lower abdomen pain ● Gallbladder: RUQ and right scapular pain (Murphy’s sign), cholecystitis (inflammation of the gallbladder) causes constant and intense pain ● Liver: RUQ and right shoulder ● Spleen: superior aspect of the left shoulder along with pain in the upper left abdomen (Kehr’s Sign)
http://www.timehd.net/appendix-and-ovary-location-in-women.html Referral Patterns
https://medical-dictionary.thefreedictionary.com/referred+pain Implications for Physical Therapy1,4 ● Positioning ○ Prone may exacerbate stomach pain or gas ○ Supine may exacerbate GERD or heartburn ● Reluctance to exercise, decreased activity tolerance, or increased fatigue ○ Nausea, abdominal pain ○ Dizziness or respiratory difficulty ● Diarrhea or loss of appetite could lead to hypoglycemia, dehydration, and therefore dizziness. ● Dysphagia could also indicate that they’re having some trouble with respiration ● Pelvic floor PT may be able to help with pain, bloating, increased urinary frequency, and release of scar tissue from GI surgery. Case Study
A 75 year old female reports to an outpatient physical therapy clinic for shoulder pain. Referral from primary care physician: “Eval and treat R shoulder pain, Grade 2 rotator cuff tear”.
Patient reports pain is relieved with ice and NSAIDs (600mg 3x/day). Previous history includes 30 pack year history of smoking and osteoporosis. In addition to shoulder pain, patient reports a dull ache just above the umbilicus, nausea (mostly at night), and “doesn’t feel very hungry most days”. Case Study-Peptic Ulcer A 75 year old female reports to an outpatient physical therapy clinic for shoulder pain. Referral from primary care physician: “Eval and treat R shoulder pain, Grade 2 rotator cuff tear”.
Patient reports pain is relieved with ice and NSAIDs (600mg 3x/day). Previous history includes 30 pack year history of smoking and osteoporosis. In addition to shoulder pain, patient reports a dull ache just above the umbilicus, nausea (mostly at night), and “doesn’t feel very hungry most days”.
What other information would you want to have? References
1. Boissonnault WG. Primary care for the physical therapist: Examination and triage. 2nd ed. St. Louis, MO: Saunders; 2011. 2. Ansari P. Acute abdominal pain. Merck Manual Website. https://www.merckmanuals.com/professional/gastrointestinal-disorders/acute-abdomen-and-su rgical-gastroenterology/acute-abdominal-pain. Updated January 2017. Accessed June 21, 2018. 3. Goodman CC, Snyder TK. Differential diagnosis for physical therapists: Screening for referral. 5th ed. Philadelphia: Saunders. 2012. https://www.advantageceus.com/sites/advantageceus2/uploads/documents/Courses/Special_Topi cs/Pain_Types_and_Patterns-_A_Differential_Diagnosis.pdf. Accessed June 22, 2018. 4. EMH Physical Therapy. Gastrointestinal and Bowel Disorders. http://emhphysicaltherapy.com/pelvic-floor-physical-therapy-for-men/gastrointestinal-and-bow el-disorders/. Accessed June 24th, 2018