Differential Diagnosis Gastrointestinal Disorders

Differential Diagnosis

Gastrointestinal Disorders

Gastrointestinal Disorders

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

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

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

GI System Anatomy

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

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

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


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


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

Ankylosing Spondylitis


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

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

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

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


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.



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


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


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

Ulcers

Normal

Gastric Ulcer

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

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

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

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

McBurney’s Point

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

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

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

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

GI Complications with NSAIDs

Voltaren Lodine Indocin Relafen Anaprox Naprosyn Toradol

Aspirin Excedrin Bufferin Advil Motrin Ibuprofen Aleve

Common Nonsteroidal Anti-inflammatory Drugs


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


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)

References “Ankylosing Spondylitis”. Retrieved 6/22/08 from the World Wide

Web. http://www.spondylitis.org/about/as.aspx Goodman CC, Snyder TE. 2007. Screening for Gastointestinal

Disease. In: Differential Diagnosis for Physical Therapists Screening for Referral. 4th 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. 2nd edition. Philadelphia, PA: Churchill Livingstone, p102.

Reese NB. 2005. Muscle and Sensory Testing. 2nd edition. St. Louis, MO. Saunders Elsevier.p253.

Rubin E, Farber JL. 1999. Pathology. 3rd edition. Philadelphia, PA: Lippincott Williams & Wilkins p693. In: Porth editor: Pathophysiology Concepts of Altered Health States, 6th edition. Philadelphia, PA: Lippincott Williams & Wilkins, p839.

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Differential Diagnosis Gastrointestinal Disorders