Achalasia: Proximal Dysphagia Due To Neuromuscular Cause Distal Dysphagia Due To Mechanical Obstruction
Achalasia: Proximal Dysphagia Due To Neuromuscular Cause Distal Dysphagia Due To Mechanical Obstruction
Achalasia: Proximal Dysphagia Due To Neuromuscular Cause Distal Dysphagia Due To Mechanical Obstruction
S/Sx:
GASTRO –ESOPHAGEAL REFLUX DISORDER
due to improper lower esophageal sphincter Heart-burn like pain usually after eating and with
relaxation recumbency
Nausea, gagging, cough or hoarseness; Heart burns Sliding Hernia (Diaphragmatic Hernia) = heartburn 30-
60 mins after meals
Strong predisposing factor to Esophageal CA
Large Sliding Hernia = heartburn, reflux and substernal
Causes: pain
Irradiation
Chemical (poison swallowing) Rolling Hernia = no reflux or heartburns but pain with
1
Infections swallowing
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Diaphragmatic Hernias
Asthma PT Mx:
cardio pulmo meds Advice to avoid Valsalva/increasing intra-abdo
Adrenergics pressure
Aminophyllline Slow return to function over 6-8 wks
Nitrates Chest PT and protection of chest tubes if post-op
Ca blockers Shaker Head Lifting
Isokinetic head lifting (look at toes) in supine x 30
Geriatrics Presentation: (1:1) x 3/day
Dysphagia, Vomiting May also be useful for swallowing disorders &
Respiratory difficulties GERD
Strengthens UES Ilioinguinal or Femoral Neuritis = due to
entrapment in sutures; resolve spontaneously
ESOPHAGEAL VARICES
Sports Hernia = pain with sudden mvts, Dilated vessels in the esophagus due to portal HTN
acceleration, twists/turns ; activites stretching abdo causing Hge
ETOH abuse is a risk
Ipsilat groin/thigh/flank/ hypogastrium
Consistent with Chronic Liver Disease/Cirrhosis
Increased pain during menstruation
Observe for signs of Hepatic Encephalopathy
Neuralgic Pain when Transversalis and Int Oblique (behavior change, asterexis, edema)
increase in tone
Normal peristalsis in upper third of esophagus and
intermittent nonperistaltic, simultaneous
contractions in body of esophagus
Intermittent chest pain with or without eating
“cork-screw” pattern
ZOLLINGER-ELLISON SYNDROME
Achalasia
Clinical triad:
Gastric Acid Hypersecretion
Recurrent Peptic Ulcer GASTRITIS
Non-Beta Islet Cell Tumor (Gastrinoma) in Pancreas Inflammation of gastric mucosa
Commonly mild to moderate chronic gastritis in
Mimics Peptic ulcers but more severe and with mid to later adult life
diarrhea Superficial gastritis is not harmful; deep into the
gastric mucosa = atrophy of gastric mucosa
MALLORY-WEISS SYNDROME Acute or Severe = ulcerative excoriation of gastric
mucosa
LES mucosal tear due to irritation
Most is caused by chronic bacterial infection; also
Due to retching, vomiting, or suddenly in increased by Alcohol and Aspirin
intra-abdo pressure as in exercise
May also be due to increased permeability of
VOMITING gastric barrier to hydrogen ions from blood =>
Upper GIT rids itself of its contents gastric ulcer
Preceded by nausea that is due to UGIT irritation,
overdistention or over-excitation
GASTRIC ATROPHY
Can be due to drugs: morphine, codeine, excess In chronic gastritis, mucosa becomes more atrophic
alcohol, anesthetics and antineoplasms and lose gastric gland digestive secretion
May also be due to an autoimmune process that
Sensory signals: upper GIT (pharynx to upper attacks the mucosa
intestines)
Afferent limb: CN X & Sympa afferent ACHLORHYDIA
Center: Vomiting Center of BS Stomach fails to secrete hydrochloric acid (pH fails
Efferent Limb: CN V, VII, IX, X, XII to go lower than 6.5 after max stimulation)
Effectors: UGIT, Diaphragm and Abdo Hypochlorhydria = diminished acid secretion
Complicaitions: electrolyte imbalances, aspiration, Loss of Intrinsic Factor in the gut Vit B12 is not
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Refer to MD if antacids relieve backpain or Hepa A, B, C are most common viral types
shoulder pain Hepa G is a recent discovery
Hepa A = oro-fecal route
Exercise and Peptic Ulcers Hepa B, C & G = blood and fluid route
HEPATIC ENCEPHALOPATHY
Aka Portosystemic Enceph SPRUE
Reversible decreased level of consciousness
Said to be due to high-CHON meals, increased Early Symptoms:
Ammonia Fatigue
In acute or chronic liver disease Depression
Insidious in ESLD Abdominal bloating
Cramps
Stage I = impaired attention, depression, Indigestion & Flatulence
personality changes, tremors and incoord Bulky, malodorous stool that are hard to flush
Stage II = drowsy, asterexis, ataxia, slurred speech Nocturia
Stage III = confusion, somnolenc, rigidity, Joint Pains
hyporeflexia Wt gain or loss
Stage IV = coma Explosive, chronic diarrhea
HEPATORENAL SYNDROME
Renal dysfunction in Portal HTN with Creatinine Late Symptoms:
>1.5 mg/dL, CHONuria <500 mg/dL Muscle wasting
Osteoporosis
Type I = rapid, leads to renal failure Low BP
Type II = insidious, progressive for months; Ascites Infertility
prominent sign Abdo distention
Tetany
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SPRUE Paresthesias
Malabsorption in the small intestine Trousseau Sign/Chvostek Sign
Easy bleeding/bruising
Nontropical Sprue = aka Idiopathic Sprue, Celiac Dermatitis Herpetiformis
Disease (in children), Gluten Enteropathy (gluten in
grains, wheat and rye destroys enterocytes)
CONSTIPATION
Tropical Sprue = tropical; treated with antibacterials Slow mvt of feces in large intestine due to dry, hard
feces in Desc Colon following over-absorption of
Malabsorption Sprue = fat absorption is impaired = fluid
Steatorrhea
May also be due to any obstruction of intestinal Obstructed beyond Stomach = equally lost acid and
mvt base
Frequently due to irregular bowel habits
Constant inhibition of normal defecation reflex, or Obstruction near Distal Colon = vomiting, rupture
use of laxatives = Atonic Colon of colon, dehydration, circulatory shock
DIARRHEA
Enteritis = inflammation due to viral or bacterial Ogilvie’s Syndrome
attack of the intestinal tract (Cholera – producing Colonic dilatation and functional obstruction
loss of fluids and lytes) without mechanical cause
affects colon only
Psychogenic Diarrhea = due to excessive parasym Associated with Hip Arthroplasties
stimulation in times of tension Abdo distention, nausea, diarrhea, flatus
Paralytic Ileus
Blood in GI:
increases peristalsis S/Sx:
Nausea + Vomiting Sudden crampy abdo pain(intermittent with
Diarrhea peristalsis)
Pain referral to shoulder or back Abdo distension
Labs: Increased BUN Vomiting
Fatigue Obstipation (unable to pass gas or stool)
Hypotension Local tenderness
Tachycardia High-pitched or absent bowel sounds
SOB Tachycardia and hypotension in dehydration or
Chronic : anemia peritonitis
Bloody stools
Inflammation of the appendix of the Colon Intestinal Angina can result to intermittent back
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IBD pts found to have characteristic personalities Avoiding milk in diet, alcohol, tobacco use, gas-
susceptible to emotional stress producing food
Fiber Supplements + Hydration
Behavioral Tx
Serotonin (5-HT)
Exercise
IBD Pain Patterns
Congenital
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REFERRED PAIN
Gastrectomy
Removal of portion or all of the stomach OBTURATOR / PSOAS ABSCESS
Billroth I pyloric portion
Billroth II distal stomach and duodenum To screen:
Heel Tap
Whipple’s Procedure Hop Test
Aka Pancreatoduodenectomy Iliopsoas MMT
Obturator Muscle Action AAROM
Palpation of Iliopsoas
in supine, with hips and knees in 90 degrees Hernias can impose problems with positioning for
flexion, palpate 1/3rd of distance from ASIS to bronchial hygiene techniques or with mobility
umbilicus for pain activities especially Hiatal Hernias (supine,
Valsalva)
Must r/o LLQ pain as this may be due to bowel
perforation with diverticulitis
Ensure PPE with managing Hepatitis patients who
Ask if symptoms are relieved with bowel would need bronchial hygiene or wound care.
movement
Ensure vaccinations are up to date when working
with this pt group
Abscess S/Sx:
Fever Consider pt’s fatigue levels due to malabsorption
Lower abdo pain and nutritional deficiencies in GI disorders when
Flexion deformity of hip planning treatment goals—consult with
Increase in symptom with Hip Extension nutritionist/dietician
Resources
GENERAL PT CONSIDERATIONS IN GI DISORDERS Guyton’s Textbook of Med Physiology, 11th ed
10
disorders that exacerbate dysphagia or GERD Goodman’s Differential Diagnosis for Physical
(forward head postures or anterior disk protrusion) Therapists, 4th Ed
Goodman’s Pathology: Implication for the PT
Helpful Mx for Swallowing Disorders: Shaker Head Boissonault’s Primary Care for the Physical
Lifting Therapist