Achalasia: Proximal Dysphagia Due To Neuromuscular Cause Distal Dysphagia Due To Mechanical Obstruction

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ACHALASIA  Wt loss, Anemia

 Lower esophageal sphincter fails to relax in  +/- heartburn or regurgitation


swallowing Medical Mx:
 Damaged neural network of MP in lower 2/3 rd of  PPIs then H2 Blockers
esophagus  Surgery (endoscopy, suturing)

 Effects: GERD PT Mx:


 Unable to swallow food for hours
 Megaesophagus  infection  death  Exercise-related GERD : avoid high-calorie/high fat
 Substernal pain meals before immediately before exercise
 Rx: balloon inflation on tip of ET; antispasmodics
 Eat small & frequent meals in upright position
 Avoiding positions that exacerbate symptoms
DYSPHAGIA  Nocturnal GERD positioning
 Difficulty in swallowing, occurring from various
etiologies  Drink between meals
 Relief: antacids, baking soda, sugarless gum
 Proximal Dysphagia = due to neuromuscular cause standing, walking

 Distal Dysphagia = due to mechanical obstruction HIATAL HERNIA


or from peptic strictures, mucosal rings or
malignancies  Abnormal protrusion of the stomach through the
esophageal hiatus of the diaphragm
 May also be described as occurring with solids,
liquids or both / constant vs intermittent / with  due to increased intra-abdo pressure, weakened
regurgitation or coughing diaphragm and/or Hiatus

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
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 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

 Genitofemoral Causalgia = less common: pain in


HERNIAS genitalia and upper thigh worse in walking,
stopping or hip hyperext
Inguinal Hernia
 Occur in the groin when sac formed from Mx:
peritoneum containing portion of intestine pushes:  Trusses /Supports with MD assessment

 Direct = through weak abdo wall  Watchful waiting


 Indirect = inguinal ring into scrotum or labia
Psoas Abscess vs Hernia
Sports Hernia  Often confused
 Due to Adductor contraction during sport, shearing  MD must differentiate
Symphysis Pubis  Psoas is softer and with ill-defined borders
 Psoas lies lateral to Femoral Artery, Hernia lies
 Or due to repetitive Transversalis and Int Oblique medial to it
stretching
 Surgical Repair:
 Give rise to Osteitis Pubis and Adductor
Tenoperiostitis Post-op: no lifting for 4-6 wks

Umbilical Hernia  In athletes: (no evidence base) isometric abdominal


 Due to increased abdo pressureexerted on a and adductor exercises 24 hrs post-op, progressed
thinned umbilical ring and fascia to conc – ecc

Femoral Hernia  Walking begun in 1st wk


 Loop of intestine into Femoral Canal  Jogging by Day 10
 Stright Line sprints by Day 21
Incisional Hernia  Later Sports specific training
 Occurs post-op
BARRETT’S ESOPHAGUS
Manifestations:  Complication of chronic GERD – esophageal cells
 Intermittent and persistent bulge replaced by intestinal cells, which can be cancerous

 Persistent pain in increased pressures (ie Valsalva)  Rx:


 Controlling GERD
 Incisional Hernia = marble sized protrusions that  Endoscopic ablation therapy
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can be pushed back; often after meals


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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

 Anti-peristalsis = prelude to vomiting; reverse PERNICIOUS ANEMIA


peristalsis  Accompanies gastric atrophy and achlorhydria
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 Complicaitions: electrolyte imbalances, aspiration,  Loss of Intrinsic Factor in the gut Vit B12 is not
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Mallory-Weiss Syndrome, malnutrition, esophageal absorbed for RBC maturation 


rupture
PEPTIC ULCER
MOTILITY DISORDERS & ANGINA-LIKE CHEST PAINS  Excoriated area of stomach or intestine due mainly
to gastric juice or upper intestinal secretions
 can present as Anterior Chest Pain, mimicking  Common at Lesser Curvature of Antral Stomach
angina  Rare at lower end of Esophagus
 Marginal Ulcer = often occur on surgical openings
Diffuse Esophageal Spasm (ie gastrojejunostomy)
 Other causative factors in Peptic Ulcers: HEPATITIS
 Smoking, alcohol and Aspirin/NSAIDs  liver inflammation and cell necrosis
 Acute vs chronic
Rx:  Results from:
 Antibiotics  Viruses – most common
 Acid-suppresants to block histamine2 receptors  Toxins
that increase acid in the gut (Ranitidine)  ETOH
 removal of 4/5th of stomach to reduce ac-d-peptic  Leukemias
juices  Lymphomas
 Gastric Vagotomy  Wilson’s disease (copper metabolism disorder)

Acute Ulcer Pain Patterns

 Thoracolumbar Junction Viral Classifications:


 Mid-thoracic back  A, B, C, D, E or G
 Right abdominal quadrant, Right Shoulder

 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

 Competitive athletes who also PUD with empty S/Sx:


stomach during performance = increase S/Sx  Abrupt onset of malaise
 Fever
 Anorexia
PANCREATIC FAILURE  Nausea, abdo discomfort and pain
 Abnormal digestion in the small intestine  Headache
 Due to Pancreatitis, Blocked Pancreatic Duct,  Jaundice
Removal of Head of Pancreas due to malignancy  Dark-colored urine
 Results to inability to get the nutrition off of
ingested food and causes fatty feces CIRRHOSIS

PANCREATITIS  hepatic parenchymal cell destruction, necrosis,


 Acute or chronic inflammation of pancreas regeneration & scar tissue formation
 Most common cause: Excess ETOH
 2nd most common cause: blocked Papilla of Vater by  Scarring and fibrosis decreases liver’s ability to
a gallstone synthesize CHONs (albumin), clotting factors and
 resulting to build up of pancreatic enzymes that bilirubin
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then digest the pancreas itself


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Hepato-Biliary Disorders Some causes:


 ETOH / Drug abuse
 any pt with undiagnosed or untreated jaundice  HAV, HCV, HDV
must be referred to MD  Hemochromatosis
 Wilson’s Disease
 Cornerstone of Liver Rx: Rest  Alpha 1 Anti-trypsin Deficiency
 Biliary Obstruction
 Most common sign of liver failure: Asterexis  Venous outflow obstruction
 Cardiac Failure
 Malnutrition
 CF
 Congenital Syphilis  Severe Sprue = malabsorption of fats along with
CHONs, Carbs, Ca, Vit K, Folic Acid and Vit B12
PORTAL HYPERTENSION
 Increase in hepatic sinusoidal pressure >6 mmHg
MALABSORPTION SYNDROME
 Complications:  Celiac Disease
 Gastroesophageal Varices  Cystic Fibrosis
 Crohn’s Disease
PT Implications  Chronic Panceatitis
 Highest pressures at night and after eating or in  Pancreatic CA
increased intraabdominal pressures  Pernicious Anemia
 Short-Gut Syndrome – often after resections or
congenital bowel shortening

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

 Mx: Hemodialysis Others:


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 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

PT Mx: Pelvic Floor Retraining, External Anal Sphincter


Training Volvulus
 Torsion of loop of intestine twisted on mesentery
 MEGACOLON that kinks bowel and disrupts blood supply
 Severe constipation, distending colon to 3-4 inches
in diameter Intussusception
 Aka Hirschprung’s Disease  Telescoping / sliding of intestine on itself
 Frequently caused by deficient ganglion cells in
Myenteric Plexus at a segment of the Sigmoid Adynamic/Paralytic Ileus
Colon  Neurogenic or muscular impairment bowel; often
in SCI
 Associated with Anterior Lumbar Fusions

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

 Ulcerative Colitis = extensive areas of the walls of


colon become inflamed and ulcerated; cause PT Mx in Obstructions:
unknown; heritable Use of TENS acutely to encourage mobility

 Taking Bismuth or Bismuth-containing meds for GI HEMORRHAGE (BLEED)


diarrhea may have dark stools and tongue
Upper vs lower
PARALYSIS OF DEFECTION IN SCI
 Injury between brain and Conus Medullaris = UGIB causes:
voluntary defecation is lost (abdo pressure and  Duodenal ulcers
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relaxing Ext Sphincter)  Gastric erosion


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 Mx: Enema in the morning after meal  Gastric ulcers


 Esophageal varices
 NSAIDs
GI OBSTRUCTION
 Common causes: CA, fibrotic constriction ff LGIB causes
ulceration or peritoneal obstruction, spasm or  IBD
paralysis of gut segment  Neoplasms
 Ano-Rectal lesions
 Obstruction at Pylorus = loss of H  Whole-body  Hemodynamic instability leading to shock
Alkalosis  Hematemesis, Hematochezia, Melena – clinical
manifestations
 Commonly caused by erosive gastritis seen:  Adhesions
 Trauma  Herniations
 Systemic illness  Volvulus (twisted bowel)
 Burns/TBI  Tumor
 Peptic Ulcers  Inflammation
 Use of NSAIDs (ASA, NSAIDs)  Fecal impaction
 Chronic ETOH  Adjacent bowel invagination

 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

GASTRIC EMPTYING DISORDERS (RETENTION)


 Abnormal emptying results from:
 Pyloric stenosis due to duodenal ulcers INTESTINAL ISCHEMIA
 Hyperglycemia  Aka Ischemic Colitis
 DKA
 Electrolyte imbalance Causes:
 Autonomic neuropathy  Thrombosis
 Post-op stasis  Intestinal Angina/Abdominal Angina
 Pernicious anemia  Embolism of Sup. Mesenteric Artery
 CVI
 Enhanced emptying results from:  Hypotension
 Vagotomy  Oral contraceptives
 Gastrectomy  NSAIDs
 Gastric or duodenal ulcers  Vasoconstrictors (Vasopressin, Dihydroergotamine,
Methamphetamine, Coccaine)
APPENDICITIS  PT Implication
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 Inflammation of the appendix of the Colon  Intestinal Angina can result to intermittent back
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 Simple/Gangrenous/Perforated pain (TL Junction)


 S/Sx:
 RLQ / Epigastric / Periumbilical abdominal INFLAMMATORY BOWEL DISEASES
fluctuating pain
 Abdo tenderness in RLQ Begins: (Inflammatory Phase)
 Vomiting with anorexia  Fever, malaise
 Constipation and failure to pass flatus  Wt loss
 Low-grade pyrexia (not greater than 102 F or 39 C)  Diarrhea
 Abdo cramps or pain
INTESTINAL OBSTRUCTIONS
 Failure of intestinal contents to propel forward Obstructed Phase:
 Persistent abdo pain  At least 3 mos of abdo pain relieved by bowel mvt
 Abdo distention with at least 3 of:
 Abdo bloating
 Common with Intestinal Arthritis  Passage of mucus
 Peripheral  Change in stool form
 Monoarticular (knee, ankle, wrist)  Altered stool frequency or difficulty in passing
 Spondylitis & Sacroilitis
 Inflammed PIP Jt of toes – oftenindicative of S/Sx:
Enteropathic Arthritis  Distended Abdo
 Constipation or diarrhea
 Symptoms with eating, emotional stress
Sequelae:  No weight loss
 Osteoporosis (CD>UC)  Tender sigmoid
 Steroid-induced bone deminiralization  Sharp cramps in the morning or after eating
 Dehydration (dry skin, headache, brittle hair,  (L) Lower Quadrant pain
incoorination, disorientation)  Upper Abdo Pain
 N+V; Foul breath
 Sour stomach; Flatus
Report to MD:
 Any increase in pain, symptoms or stool output IBS Mx:

 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

 Crohn’s involving Terminal Ileum: DIVERTICULAR DISEASE


 LBP
 Right Lower Quadrant Pain  Diverticula is an out pocketing or herniation of the
 Iliopsoas Abscess or Ureteral Obstruction mucosa of the large intestine through the muscle
 Buttock, Hip, Thigh, Knee Pain producing antalgia layers of the intestinal wall
 Diverticulosis = outpouchings
 Diverticulitis = when particles stuck
IRRITABLE BOWEL SYNDROME in diverticula cause inflammation
 Functional Bowel Disorder;
Spastic/Nervous/Irritable Colon Causes:
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 Congenital
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 ‘Enhanced Visceral Nociception’  Atrophy/weakness of bowel muscles


 Obesity
 Inconsistent motility of colon (constipation or  Chronic constipation
diarrhea); not inflammatory and may occur in the  Low fiber diet; poorly digested food
small and large intestines  NSAIDs, Acetaminophen

 Extra-GI associations: FMS, CFS, TMJ Disorder, S/Sx:


Chronic Pelvic Pain, Serotonin level changes in the  Achy LLQ and tenderness with relief in BM
gut; possible hx of abuse  LBP
 Urinary frequency
Clinical Manifestations:  Distended tympanic abdo
 Fever (increased WBC) En bloc removal of duodenum, portion of distal
 Constipation ↔ Diarrhea stomach and jejunum, gall bladder, common bile
 Bloody stools, painless duct and regional lymph nodes
 N + V; anorexia
Reserved for chronic pancreatitis or Pancreatic CA
Mx:
 High fiber diet
 Hydration + Bulk Laxatives GI PAIN PATTERNS
 Exercise during remission  Esophageal Dysfunction = Mid-Thoracic Pain
 Pericardium, Diaphragm and Liver = Shoulder Pain
 Avoid exercises/activities that increase intrabado (C3-C5) 
pressure (lifting, valsalva etc)  Gallbladder, Stomach, Pancreas and Small
Intestines = Mid-back and Scapular Region (T6-T9,
Splanchnic Nerve)
PT Implications
 Back pain common  Air/blood in abdo cavity; perforation of ulcers;
 Abcess may occur = Hip/Thigh pain diverticular disease; 24-48 post-laparoscopy;
spleen rupture = Left Shoulder Pain
 Assess Pinch-an-Inch

Common GI Surgeries REFERRED PAIN

 Appendectomy  Colon, Appendix and Pelvic viscera = T10 – T11


 Cholecystectomy nerve segments
 Colectomy
 Colostomy  Sigmoid, Rectum, Ureters and Testes = Pelvis, Flank,
 Ileostomy low back or sacral pains (T11 – L1; S2-S4)
 End Colostomy
Bringing functional end of intestine out onto ODYNOPHAGIA
abdominal surface and forming stoma  Pain during swallowing, can be caused by
esophagitis or esophageal spasm
 Double-barrel Colostomy
2 separate stomas, one functional and one distal ESOPHAGITIS vs CORONARY ISCHEMIA
stoma (mucous fistula) connected to rectum to  Upright sitting relives esophagitis, CI is relieved by
drain small amounts of mucous material nitroglycerine or supine positioning
SHOULDER PAIN
 Loop Colostomy  Pain on left shoulder due to free air or blood in the
Bringing loop of bowel through incision in abdo abdominal cavity (ruptured spleen) = KEHR’S SIGN
wall; incision is made in the bowel for passage of
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stool (temporary colostomy)


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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

MCBURNEY’S POINT PAIN  Review labs results: Hematocrit and Hemoglobin


levels 
 Caused by inflammation to peritoneum in acute
appendicitis or peritonitis  Esophageal Varices and Portal HTN pts must not be
positioned in supine, there is a risk of variceal
 Appendix receives sympa supply from T11, same rupture
area as McBurney’s point
 Avoid Valsalva in pts with Esophageal Varices and
 Point is halfway between right ASIS and umbilicus Portal HTN (ie coughing) 
—palpate for tenderness in full supine
 Ascites and abdominal incisions can increase risk of
REBOUND TENDERNESS (BLUMBERG’S SIGN) respiratory compromise due to pain and poor
 To asses peritonitis or appendicitis cough
 Palpate away from side of expected pain (at LLQ or
flank)  Pelvic Floor Retraining can be useful for
 Deep palpation then abrupt release (rebound) constipation
 If this elicits pain on rebound—there may be
inflammation of the peritoneum 

Resources
GENERAL PT CONSIDERATIONS IN GI DISORDERS  Guyton’s Textbook of Med Physiology, 11th ed
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 Paz & West’s Acute Care Handbook for Physical


 Be aware of positioning precautions for esophageal Therapists, 2nd Ed
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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

 Aerobic & Strengthening Exercise can decrease GI


transit time

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