1. Differential Diagnosis Gastrointestinal Disorders

2. Can refer pain to the sternal region, shoulder, scapula, neck, mid back, low back, hip, pelvis and sacrum Pain may mimic musculoskeletal lesions If due to GI disorder, pain is usually accompanied by other systemic signs and symptoms Intraabdominal diseases involving ulceration or infection of the mucosal lining most commonly refer pain to the musculoskeletal system

3. GI related symptoms Abdominal pain Dysphagia Odynophagia Melena Epigastric pain with radiation to the back Symptoms affected by food Early satiety with weight loss Constipation Diarrhea Fecal incontinence Arthralgia Referred shoulder pain Psoas abscess Tenderness over McBurney’s point

4. Gastrointestinal disorders Abdominal (Visceral) pain Occurs in the midline – abdominal organs receive sensory afferents from both sides of the spinal cord Site of pain corresponds to the dermatome from which the diseased organ receives its innervation Pain is not well localized Visceral pain fibers are sensitive only to stretch or tension

5. GI System Anatomy

6. GI disorders – Referred pain Liver, diaphragm and pericardium (C3-C5) – refer pain to the shoulder Gallbladder, stomach, pancreas and small intestines (T6-T9) – refer pain to the midback and scapula Colon, appendix and pelvic viscera (T10-T11) Sigmoid colon, rectum, ureters and testes (T11-L1, S2-S4) – refer pain to the pelvis, flank, low back or sacrum

7. GI disorders – Referred pain Referred distribution area may develop: Hyperesthesia – Excessive sensibility to sensory stimuli Hyperalgesia – Excessive sensibility to painful stimuli Referred pain may occur alone If accompanied by visceral pain, the visceral pain usually develops first The client usually does not connect the two sets of symptoms

8. Arthralgia due to GI disorders Asymmetric, migratory and usually only affects one or two joints at a time Accompanied by fever, malaise, skin rash or lesions, nail bed changes, iritis or conjunctivitis Joint pain and accompanying symptoms may not occur simultaneously. Usually accompanying symptoms occur 1-3 weeks prior to the onset of joint pain Peripheral joints (knees > ankles > shoulders > wrists > hands and feet) are most commonly affected

9. Arthralgia due to GI disorders Knee Effusion is common Muscle atrophy occurs with chronic condition Stiffness, pain, tenderness and decreased ROM No permanent deformity persists when GI disorder is properly treated

10. Arthralgia due to GI disorders Spondylitis with sacroilitis LBP and morning stiffness Improves with activity Radiographic findings consistent with ankylosing spondylitis with bilateral SI joint involvement “Bamboo spine” will result if untreated

11. Ankylosing Spondylitis

12. Arthralgia due to GI disorders Enthesitis (Inflammation involving the bony insertion of tendons and ligaments) Heel pain - Swelling and tenderness at the Achilles tendon insertion or the calcaneal attachment of the plantar fascia Can also occur at the knee, ischial tuberosities, greater trochanter, costovertebral and manubriosternal joints

13. Kehr’s sign Pain in the left shoulder due to free air or blood in the abdominal cavity May occur after a ruptured spleen Patient may or may not recall precipitating trauma such as a sharp blow during an athletic event, a fall or MVA Patient may not connect the traumatic event to complaints of shoulder pain

14. Psoas Abscess Usually due to spread of inflammation or infection from an adjacent structure Osteomyelitis of the ilium or septic arthritis of the SI joint can penetrate the muscle sheath of the iliacus or the psoas muscle producing an abscess Symptoms include fever, night sweats, lower abdominal or back pain, referred pain to the hip, medial thigh, groin or knee May develop antalgic gait pattern

15. Differential diagnosis of hip pain Heel tap Gently tap the heel of the involved leg or have the patient hop on the involved leg If the patient has peritoneal inflammation, they will have a painful expression and complaint of right lower quadrant pain with testing, or they will be unable to tolerate or complete the test due to pain If pain is musculoskeletal in origin, tapping the heel will not reproduce pain

16. Differential diagnosis of hip pain Iliopsoas muscle test Perforated appendix or inflammed peritoneum can press on and irritate the iliopsoas muscle Have the patient perform an active SLR in supine position. Therapist applies resistance at the distal thigh. Alternatively, have the patient lie on the unaffected side. Passively extend the affected leg at the hip. If either of the above tests produces increased right abdominal, flank or pelvic pain it is suggestive of an inflamed appendix or peritoneum Pain and/or tenderness in the left lower abdomen may be caused by bowel perforation associated with diverticulitis.

17. Differential diagnosis of hip pain

18. Palpate the iliopsoas muscle In supine, fully support the patient’s legs in 90/90. Locate and palpate the iliopsoas muscle one third of the distance between the ASIS and the umbilicus If the patient c/o LBP with palpation, this is indicative of a tight or contracted iliopsoas If palpation refers pain into the right lower quadrant, this is indicative of peritoneal inflammation or iliopsoas abscess

19. Differential diagnosis of hip pain Obturator muscle test In supine position have the patient active assistively flex the hip and knee to 90/90 The therapist them performs passive hip internal and external rotation If normal, this motion should not be painful If pain is reproduced in the right lower abdomen or the pelvic region, it is indicative of peritoneal infection or inflammation

20. Differential diagnosis of hip pain

21. Ulcers Pain is described as burning, gnawing, cramping or aching Pain comes in waves that last several minutes (not hours) Pain may radiate below the costal margins into the back, and rarely into the shoulder Pain pattern is directly related to the secretion of digestive enzymes and the presence or absence of food

22. Ulcers Normal Gastric Ulcer

23. Diverticulitis Symptom of left lower abdominal pain or tenderness Screen for with iliopsoas and obturator tests Confirmed by accompanying fever, bloody stools, and elevated WBC count

24. Appendicitis Classic symptoms of right lower abdominal pain, nausea and vomiting May be accompanied by high fever, coated tongue and bad breath Pain may be referred to the thigh or right testicle Pain comes in waves and is aggravated by movement Patients often assume a flexed posture to relieve abdominal muscle tension

25. Appendicitis Important to check for in the elderly population with c/o hip or thigh pain May not present with classic sign of peritonitis due to lack of abdominal muscle tone Specific tests should include iliopsoas, obturator abscess and McBurney’s point

26. McBurney’s point Location of parietal pain caused by inflammation of the peritoneum in acute appendicitis or peritonitis Locate by palpation with patient in supine McBurney’s point is located half way between the ASIS and the umbilicus Reproduction of pain with palpation is indicative of appendicitis

27. McBurney’s Point

28. Rebound tenderness Used to test for hip, pelvic or flank pain from peritonitis While palpating McBurney’s point, press the fingers in firmly and slowly Then quickly withdraw the fingers Pain induced or increased by quick withdrawal indicates inflamed peritoneum

29. Acute Pancreatitis Inflammation of the pancreas that may result in autodigestion of the pancreas by its own enzymes Symptoms of abrupt abdominal pain in midepigastrium Pain is described as penetrating and may radiate into the back Pain increases in intensity over several hours and can last several days

30. Acute Pancreatitis Pain is worse with walking or lying supine Pain is relieved with sitting or leaning forward Associated symptoms include nausea, vomiting, fever, sweating, tachycardia, malaise, weakness and jaundice Patients with chronic pancreatitis may have epigastric and left upper quadrant pain with referred pain into the upper left lumbar region

31. Pancreatic Cancer Initial symptoms are usually vague and nonspecific Most common symptoms are anorexia and weight loss, upper abdominal pain with radiation into the back, and jaundice May have constipation, nausea, vomiting and weakness LBP is a common symptom and may be the first or only symptom Sitting up and leaning forward may provide some relief – indicates the tumor has spread beyond the pancreas and is inoperable

32. GI Complications with NSAIDs Voltaren Lodine Indocin Relafen Anaprox Naprosyn Toradol Aspirin Excedrin Bufferin Advil Motrin Ibuprofen Aleve Common Nonsteroidal Anti-inflammatory Drugs

33. GI Complications with NSAIDs NSAIDs have become increasingly popular because of their analgesic, antiinflammatory, antipyretic and antithrombotic actions They have deleterious effects on the entire GI tract Most obvious clinical effect is on the gastroduodenal mucosa NSAID induced GI bleeding is a major cause of morbidity and mortality among the elderly

34. GI Complications with NSAIDs GI complications include ulcerations, hemorrhage, perforation, stricture formation, and exacerbation of inflammatory bowel disease Other complications Suppression of cartilage repair and synthesis Fluid retention Kidney damage Liver damage Skin reactions Nervous system impairments (headaches, depression, confusion, memory loss, mood changes, and ringing in the ears)

35. References “Ankylosing Spondylitis”. Retrieved 6/22/08 from the World Wide Web. http://www.spondylitis.org/about/as.aspxhttp://www.spondylitis.org/about/as.aspx Goodman CC, Snyder TE. 2007. Screening for Gastointestinal Disease. In: Differential Diagnosis for Physical Therapists Screening for Referral. 4 th edition. St. Louis, MO: Saunders Elsevier. p366-408. Koopmeiners MB. 1995. Screening for Gastrointestinal System Disease. In: Boissonnault editor: Examination in Physical Therapy Practice Screening for Medical Disease. 2 nd edition. Philadelphia, PA: Churchill Livingstone, p102. Reese NB. 2005. Muscle and Sensory Testing. 2 nd edition. St. Louis, MO. Saunders Elsevier.p253. Rubin E, Farber JL. 1999. Pathology. 3 rd edition. Philadelphia, PA: Lippincott Williams & Wilkins p693. In: Porth editor: Pathophysiology Concepts of Altered Health States, 6th edition. Philadelphia, PA: Lippincott Williams & Wilkins, p839.