Screening for Gastrointestinal Disease

Chapter 8


Screening for Gastrointestinal Disease


A great deal of new understanding of the enteric system and its relationship to other systems has been discovered over the last decade. For example, it is now known that the lining of the digestive tract from the esophagus through the large intestine (Fig. 8-1) is lined with cells that contain neuropeptides and their receptors. These substances, produced by nerve cells, are a key to the mind-body connection that contributes to the physical manifestation of emotions.1,2



image


Fig. 8-1 Organs of the digestive system; see also Fig. 9-1. (From Hall JE: Guyton and Hall textbook of medical physiology, ed 12, Philadelphia, 2010, WB Saunders.)


In addition to the classic hormonal and neural negative feedback loops, there are direct actions of gut hormones on the dorsal vagal complex. The person experiencing a “gut reaction” or “gut feeling” may indeed be experiencing the direct effects of gut peptides on brain function.3


The association between the enteric system, the immune system, and the brain (now a part of the research referred to as psychoneuroimmunology (PNI) has been clearly established and forms an integral part of gastrointestinal (GI) symptoms associated with immune disorders such as fibromyalgia, systemic lupus erythematosus, rheumatoid arthritis, chronic fatigue syndrome, and others.


Researchers estimate that more than two thirds of all immune activity occurs in the gut. There are more T cells in the intestinal epithelium than in all other body tissues combined. The gamma delta T cells form the forefront of the immune defense mechanism. They act as an early warning system in the cells lining the intestines, which are heavily exposed to microorganisms and toxins.4,5 In some people, the wall of the gut seems to have been breached, either because the network of intestinal cells develops increased permeability (a syndrome referred to as “leaky gut”) or perhaps because bacteria and yeast overwhelm it and migrate into the bloodstream.


Allowing undigested food or bacteria into the bloodstream sets in motion a chain of events as the immune system reacts. The body responds as if to an illness and expresses it in a number of ways such as a rash, diarrhea, GI upset, joint pain, migraines, and headache. The exact cause for these microscopic breaches remains unknown, but food allergies, too much aspirin or ibuprofen, certain antibiotics, excessive alcohol consumption, smoking, or parasitic infections may be implicated.


All of these associations and new findings support the need for the therapist to assess carefully the possibility of GI symptoms present but unreported. This is especially important when considering the fact that GI tract problems can sometimes imitate musculoskeletal dysfunction.


GI disorders can refer pain to the sternal region, shoulder and neck, scapular region, mid-back, lower back, hip, pelvis, and sacrum. This pain can mimic primary musculoskeletal or neuromuscular dysfunction, causing confusion for the physical therapist or for the physician assessing the client’s chief complaint.


Although these neuromusculoskeletal symptoms can occur alone and far from the actual site of the disorder, the client usually has other systemic signs and symptoms associated with GI disorders that should give the therapist who does a thorough investigation grounds for suspicion.


A careful interview to screen for systemic illness should include a few important questions concerning the client’s history, prescribed medications, and the presence of any associated signs or symptoms that would immediately alert the therapist about the need for medical follow-up. The most common intraabdominal diseases that refer pain to the musculoskeletal system are those that involve ulceration or infection of the mucosal lining. Drug-induced GI symptoms can also occur with delayed reactions as much as 6 or 8 weeks after exposure to the medication. The most common occurrences are antibiotic colitis; nausea, vomiting, and anorexia from digitalis toxicity; and nonsteroidal antiinflammatory drug (NSAID)–induced ulcers.



Signs and Symptoms of Gastrointestinal Disorders


Any disruption of the digestive system can create symptoms such as nausea, vomiting, pain, diarrhea, and constipation. The bowel is susceptible to altered patterns of normal motility caused by food, alcohol, caffeine, drugs, physical and emotional stress, and lifestyle (e.g., lack of regular exercise, tobacco use). GI effects of chemotherapy include nausea and vomiting, anorexia, taste alteration, weight loss, oral mucositis, diarrhea, and constipation.


Symptoms, including pain, can be related to various GI organ disturbances and differ in character, depending on the affected organ. The most clinically meaningful GI symptoms reported in a physical therapy practice include




Abdominal Pain


As we enter into this next discussion on primary and referred abdominal pain patterns, be aware that each pain pattern has listed with it both the sympathetic nerve distribution to the viscera (i.e., autonomic nervous system innervation of the structure) and the anatomic location of radiating or referred pain from the viscera or GI segment involved in the primary pain patterns.


Whenever possible, labels are used to differentiate between sympathetic nerve innervations of the viscera and anatomic locations of the pain. For example, the small intestine (viscera) is innervated by T9 to T11 but refers (somatic) pain to the L3 to L4 (anatomic) lumbar spine.



Primary Gastrointestinal Visceral Pain Patterns


Visceral pain (internal organs) occurs in the midline because the digestive organs arise embryologically in the midline and receive sensory afferents from both sides of the spinal cord. The site of pain generally corresponds to dermatomes from which the visceral organs receive their innervation (see Fig. 3-3). Pain is not well localized because innervation of the viscera is multisegmental over up to eight segments of the spinal cord with fewer nerve endings than other sensitive organs.


The most common primary pain patterns associated with organs of the GI tract are depicted in Fig. 8-2. Reasons for abdominal pain fall into three broad categories: inflammation, organ distention (tension pain), and necrosis (ischemic pain). The underlying cause can be life-threatening, requiring a quick assessment and fast referral.



Pain in the epigastric region occurs anywhere from the midsternum to the xiphoid process from the heart, esophagus, stomach, duodenum, gallbladder, liver, and other mediastinal organs corresponding to the T3 to T5 sympathetic nerve distribution. The client may report the pain radiates around the ribs or straight through the chest to the thoracic spine at the T3 to T6 or T7 anatomic levels.


Pain in the periumbilical region (T9 to T11 nerve distribution) occurs with impairment of the small intestine (see Fig. 8-15), pancreas, and appendix. Primary pain in the periumbilical region usually sends the client to a physician. However, pain around the umbilicus may be accompanied by low back pain. In the healthy adult who is not obese and does not have a protruding abdomen, the umbilicus is level with the disk located anatomically between the L3 and L4 vertebral bodies.


The physical therapist is more likely to see a client with anterior abdominal and low back pain at the same level but with alternating presentation. In other words, first the client experiences periumbilical pain with or without associated GI signs and symptoms, then the painful episode resolves. Later, the client develops low back pain with or without GI symptoms but does not realize there is a link between these painful episodes. It is at this point the client presents in a physical therapy practice.


Pain in the lower abdominal region (hypogastrium) from the large intestine and/or colon may be mistaken for bladder or uterine pain (and vice versa) by its suprapubic location. Referred pain at the same anatomic level posteriorly corresponds to the sacrum (see Fig. 8-16). The large intestine and colon are innervated by T10 to L2, depending on the location (e.g., ascending, transverse, descending colon).


The abdominal viscera are ordinarily insensitive to many stimuli, such as cutting, tearing, or crushing, that when applied to the skin evokes severe pain. Visceral pain fibers are sensitive only to stretching or tension in the wall of the gut from neoplasm, distention, or forceful muscular contractions secondary to bowel obstruction or spasm.


Tension pain can occur as a result of bowel obstruction; constipation; and pus, fluid, or blood accumulation from infection or other causes. The rate that tension develops must be rapid enough to produce pain; gradual distention, such as with malignant obstruction, may be painless unless ulceration occurs. Rapid, peristalsis forces of the bowel trying to eliminate irritating substances can cause tension pain described as “colicky” pain. Individuals with tension pain have trouble finding a comfortable position. They will constantly shift positions to try and find a comfortable position.


Visceral organs of the GI tract (particularly hollow organs such as the intestines) respond to stretching and distention as pain, more so than typical tissue injury caused by cutting or crushing. Because of similar innervation, it is often difficult to distinguish pain associated with the heart from pain caused by an esophageal disorder.


One difference between visceral organ pain and pain from the parietal peritoneum is that the parietal peritoneum is innervated by nerves that travel with the somatic nerves, providing a more precise location of pain. This is noted with acute appendicitis, when early, vague pain (from inflammation of the appendix) is replaced by more localized pain at McBurney’s point once the inflammation involves the parietal peritoneum.


Inflammatory pain arising from the visceral or parietal peritoneum (e.g., acute appendicitis) is described as steady, deep, and boring. It can be poorly localized as when the visceral peritoneum is involved or more localized with parietal peritoneum involvement. Individuals with inflammatory pain seek a quiet position (often with the knees bent or in a curled up/fetal position) without movement.


Ischemia (deficiency of blood) may produce visceral pain by increasing the concentration of tissue metabolites in the region of the sensory nerve. Pain associated with ischemia is steady pain, whether this ischemia is secondary to vascular disease or due to obstruction causing strangulation of bowel tissue. The pain is sudden in onset and extremely intense. It progresses in severity and is not relieved by analgesics.


Additionally, although the viscera experience pain, the visceral peritoneum (membrane enveloping organs) is not sensitive to cutting. Except in the presence of widespread inflammation or ischemia, it is possible to have extensive disease without pain until the disease progresses enough to involve the parietal peritoneum.


Visceral pain is usually described as deep aching, boring, gnawing, vague burning, or deep grinding as opposed to the sharp, pricking, and knifelike qualities of cutaneous pain. When referred to the somatic regions of the low back, hip, or shoulder, the sensation is vague and poorly localized because visceral afferents provide input over multiple segments of the spinal cord. As mentioned, afferents from different abdominal locations converge on the same dorsal nerve roots, which may be shared with the more precisely developed somatic sensory pathways.



Referred Gastrointestinal Pain Patterns


Sometimes visceral pain from a digestive organ is felt in a location remote from the usual anterior midline presentation. The referred pain site still lies within the dermatomes of the dorsal nerve roots serving the painful viscera. Referred pain is often more intense and localized than typical visceral pain. Afferent nerve impulses transmit pain from the esophagus to the spinal cord by sympathetic nerves from T5 to T10. Integration of the autonomic and somatic systems occurs through the vagus and the phrenic nerves. There can be referred pain from the esophagus to the mid-back and referred pain from the mid-back to the esophagus. For example, esophageal dysfunction can present as anterior neck pain or mid-thoracic spine pain and disk disease of the mid-thoracic spine can masquerade as esophageal pain.


Client history and the presence or absence of associated signs and symptoms will help guide the therapist. For example, a client with mid-back pain from esophageal dysfunction will not likely report numbness and tingling in the upper extremities or bowel and bladder changes such as you might see with disk disease. Likewise, disk involvement with referred pain to the esophagus will not cause melena or symptoms associated with meals.


Visceral afferent nerves from the liver, respiratory diaphragm, and pericardium are derived from C3 to C5 sympathetics and reach the central nervous system (CNS) via the phrenic nerve (see Fig. 3-3). The visceral pain associated with these structures is referred to the corresponding somatic area (i.e., the shoulder).


Afferent nerves from the gallbladder, stomach, pancreas, and small intestine travel through the celiac plexus (network of ganglia and nerves supplying the abdominal viscera) and the greater splanchnic nerves and enter the spinal cord from T6 to T9. Referred visceral pain from these visceral structures may be perceived in the mid-back and scapular regions.


Afferent stimuli from the colon, appendix, and pelvic viscera enter the 10th and 11th thoracic segments through the mesenteric plexus and lesser splanchnic nerves. Finally, the sigmoid colon, rectum, ureters, and testes are innervated by fibers that reach T11 to L1 segments through the lower splanchnic nerve and through the pelvic splanchnic nerves from S2 to S4. Referred pain may be perceived in the pelvis, flank, low back, or sacrum (Case Example 8-1).



Case Example 8-1   Colon Cancer


A 66-year-old university professor consulted with a physical therapist after twisting his back while taking the garbage out. He reported experiencing ongoing, painful, low back symptoms 3 weeks after the incident. The objective assessment was consistent with a strain of the right paraspinal muscles with overall diminished lumbar spinal motion consistent with this gentleman’s age. Given the reported mechanism of injury and the results of the examination consistent with a musculoskeletal problem, a medical screening examination was not included in the interview. A home exercise program was initiated, including stretching and conditioning components.


When the client did not return for his follow-up appointment, telephone contact was made with his family. The client had been hospitalized after collapsing at work. A medical diagnosis of colon cancer was determined. The family reported he had been experiencing digestive difficulties “off and on” and low back pain for the past 3 years, always alternately and never simultaneously. The client died 6 weeks later.


In this case, the only red flag suggesting the need for medical screening was the client’s age. However, the therapist did not ask about any associated signs and symptoms. We must always remember that even with a known and plausible reason for the injury, the client may wrongfully attribute symptoms to a logical event or occurrence. This man had been experiencing both abdominal symptoms and referred back pain, but since these episodes did not occur at the same time, he did not see a connection between them.


Always finish every interview with this question: “Are you having any other symptoms of any kind anywhere else in your body?”


Hyperesthesia (excessive sensibility to sensory stimuli) of skin and hyperalgesia (excessive sensibility to painful stimuli) of muscle may develop in the referred pain distribution. As mentioned in Chapter 3, in the early stage of visceral disease, sympathetic reflexes arising from afferent impulses of the internal viscera can be expressed first as sensory, motor, and/or trophic changes in the skin, subcutaneous tissues, and/or muscles. The client may present with itching, dysesthesia, skin temperature changes, perspiration, or dry skin.


The viscera do not perceive pain, but the sensory side is trying to get the message out that something is wrong by creating sympathetic sudomotor changes. When the afferent visceral pain stimuli are intense enough, discharges at synapses within the spinal cord cause this reflex phenomenon, usually transmitted by peripheral nerves of the same spinal segment(s). Thus the sudomotor changes occur as an automatic reflex along the distribution of the somatic nerve.


Remember from our discussion of viscerogenic pain patterns in Chapter 3 that any structure touching the respiratory diaphragm can refer pain to the shoulder, usually to the ipsilateral shoulder, depending on where the direct pressure occurs. Anyone with upper back or shoulder pain and symptoms should be asked a few general screening questions about the presence of GI symptoms.


Referred pain to the musculoskeletal system can occur alone, without accompanying visceral pain, but usually visceral pain (or other symptoms) precedes the development of referred pain. The therapist will find that the client does not connect the two sets of symptoms or fails to report abdominal pain and GI symptoms when experiencing a painful shoulder or low back, thinking these are two separate problems. For a more complete discussion of the mechanisms behind viscerogenic referred pain patterns, see Chapter 3.


Most of what has been presented here has dealt with the sensory side of the clinical presentation. There can be motor effects of GI dysfunction, too. For example, contraction, guarding, and splinting of the rectus abdominis and muscles above the umbilicus can occur with dysfunction of the stomach, gallbladder, liver, pylorus, or respiratory diaphragm. Impairment of the ileum, jejunum, appendix, cecum, colon, and rectum are more likely to result in muscle spasm of the rectus abdominis below the umbilicus.6


At the same time, impairment of these GI structures can cause muscle dysfunction in the back (thoracic and lumbar spine) with loss of motion of the involved spinal segments. The clinical picture is one that is easily confused with primary pathology of the spinal segment.6 Once again, the history and associated signs and symptoms help the therapist sort through the clinical presentation to reach a differential diagnosis. A thorough screening process is essential in such cases.



Dysphagia


Dysphagia (difficulty swallowing) is the sensation of food catching or sticking in the esophagus. This sensation may occur (initially) just with coarse, dry foods and may eventually progress to include anything swallowed, even thin liquids and saliva. Dysphagia may be caused by achalasia, a process by which the circular and longitudinal muscular fibers of the lower esophageal sphincter fail to relax, producing an esophageal obstruction.


Other possible GI causes of dysphagia include peptic esophagitis (inflammation of the esophagus) with stricture (narrowing), gastroesophageal reflux disease (GERD), and neoplasm (Case Example 8-2). Dysphagia may be a symptom of many other disorders unrelated to GI disease (e.g., stroke, Alzheimer’s disease, Parkinson’s disease). Certain types of drugs, including antidepressants, antihypertensives, and asthma drugs, can make swallowing difficult.



Case Example 8-2   Esophageal Cancer


An obese 88-year-old woman with a total knee replacement (TKR) was referred for rehabilitation because of loss of motion, joint swelling, and persistent knee pain. She was accompanied to the clinic for each session by one of her three daughters. Over a period of 2 or 3 weeks, each daughter commented on how much weight the mother had lost. When questioned, the client complained of a loss of appetite and difficulty in swallowing, but she had been evaluated and treated only for her knee pain by the orthopedist. She was encouraged to contact her family doctor for evaluation of these red flag symptoms and was subsequently diagnosed with esophageal cancer.


The presence of dysphagia requires prompt attention by the physician. Medical intervention is based on a subsequent endoscopic examination.




Gastrointestinal Bleeding


Occult (hidden) GI bleeding can appear as mid-thoracic back pain with radiation to the right upper quadrant. Bleeding may not be obvious; serial Hemoccult tests and laboratory tests (checking for anemia and iron deficiency) are needed. A medical doctor should evaluate any type of bleeding. Ask about the presence of other signs such as blood in the vomit or stools (Box 8-1). Coffee ground emesis (vomit) may indicate a perforated peptic or duodenal ulcer.



Box 8-1   Signs of Gastrointestinal Bleeding




Bloody diarrhea may accompany other signs of ulcerative colitis. Diarrhea and ulcerative colitis are discussed in greater depth separately in this chapter. Bright red blood usually represents pathology close to the rectum or anus and may be an indication of rectal fissures (e.g., history of anal intercourse) or hemorrhoids but can also occur as a result of colorectal cancer.


Melena, or black, tarry stool, occurs as a result of large quantities of blood in the stool. When asked about changes in bowel function, clients may describe black, tarry stools that have an unusual, noxious odor. The odor is caused by the presence of blood, and the black color arises as the digestive acids in the bowel oxidize red blood cells (e.g., bleeding esophageal varices, stomach or duodenal ulceration). Melena is very sticky and does not clean well.


It may be necessary to ask about bowel smears on the undergarments or difficulty getting wiped clean after a bowel movement. The following series may guide the therapist in this area:



image Follow-Up Questions




After going through the questions, it may be helpful to leave the back door open. Perhaps leave the client with this thought:



Esophageal varices are dilated blood vessels, usually secondary to alcoholic cirrhosis of the liver. Blood that would normally be pumped back to the heart must bypass the damaged liver. The blood then “backs up” through the esophagus. Ruptured esophageal varices are an emergent, life-threatening condition. Vascular abnormalities of the stomach causing bleeding may include ulcers.


The client should be asked about the presence of any blood in the stool to determine whether it is melenic (from the upper GI tract; ask about a history of NSAID use) or bright red (from the distal colon or rectum). Bleeding from internal or external hemorrhoids (enlarged veins inside or outside the rectum), rectal fissures, or colorectal carcinoma can cause bright red blood in the stools. Rectal bleeding from anal lesions or fissures can occur in the homosexual population who are sexually active. Women engaging in anal intercourse can also be affected. A brief sexual history may be indicated in some cases.


Reddish or mahogany-colored stools can occur from eating certain foods, such as beets, or significant amounts of red food coloring but can also represent bleeding in the lower GI/colon. Medications that contain bismuth (e.g., Kaopectate, Pepto-Bismol, Bismatrol, Pink Bismuth) can cause darkened or black stools and the client’s tongue may also appear black.


Clients who have received pelvic radiation for gynecologic, rectal, or prostate cancers have an increased risk for radiation proctitis, which can cause subsequent (delayed) rectal bleeding episodes. Be sure and ask about a past history of cancer and radiation treatment.



Epigastric Pain with Radiation


Epigastric pain perceived as intense or sharp pain behind the breastbone with radiation to the back may occur secondary to long-standing ulcers. For example, the client may be aware of an ulcer but does not relate the back pain to the ulcer. Close questioning related to GI symptoms can provide the therapist with knowledge of underlying systemic disease processes.


Anyone with epigastric pain accompanied by a burning sensation that begins at the xiphoid process and radiates up toward the neck and throat may be experiencing heartburn. Other common symptoms may include a bitter or sour taste in the back of the throat, abdominal bloating, gas, and general abdominal discomfort. Heartburn is often associated with GERD. It can be confused with angina or heart attack when accompanied by chest pain, cough, and shortness of breath (SOB). A physician must evaluate and diagnose the cause of epigastric pain or heartburn.


A screening interview and evaluation is especially helpful when clients have neglected medical treatment for so long that epigastric back pain may in turn have created biomechanical changes in muscular contractions and spinal movement. These changes eventually create pain of a biomechanical nature.7 The client then presents with enough true musculoskeletal findings such that a diagnosis of back dysfunction can be supported. However, the symptoms may be associated with a systemic problem. A good medical history can be a valuable tool in revealing the actual cause of the back pain.



Symptoms Affected by Food


Clients may or may not be able to relate pain to meals. Pain associated with gastric ulcers (located more proximally in the GI tract) may begin within 30 to 90 minutes after eating, whereas pain associated with duodenal or pyloric ulcers (located distally beyond the stomach) may occur 2 to 4 hours after meals (i.e., between meals). Alternatively stated, food is not likely to relieve the pain of a gastric ulcer, but it may relieve the symptoms of a duodenal ulcer.


The client with a duodenal ulcer or cancer-related pain may report pain during the night between midnight and 3:00 am. Ulcer pain may be differentiated from the nocturnal pain associated with cancer by its intensity (7 or higher on a scale from 0 to 10) and duration (constant). More specifically, the gnawing pain of an ulcer may be relieved by eating, but the intense, boring pain associated with cancer is not relieved by any measures.


Ask the client with nighttime shoulder, neck, or back pain to eat something and assess the effect of food on these symptoms. Anyone whose musculoskeletal pain is altered (increased or decreased) or eliminated by food should be screened more thoroughly and referred for further medical evaluation when appropriate. Anyone with a previous history of cancer and nighttime pain must also be evaluated more closely. This is true even if eating has no effect on the client’s symptoms.




Constipation


Constipation is defined clinically as being a condition of prolonged retention of fecal content in the GI tract resulting from decreased motility of the colon or difficulty in expelling stool.


The Rome III Diagnostic criteria for functional constipation defines this condition as hard, lumpy stools; stools that are difficult to expel; infrequent stools (less than three per week); or a feeling of incomplete evacuation after defecation and general discomfort.9,10 Constipated clients with tender psoas trigger points (TrPs) may report anterior hip, groin, or thigh pain when the fecal bolus presses against the TrPs.11


Intractable constipation is called obstipation and can result in a fecal impaction that must be removed. Back pain may be the overriding symptom of obstipation, especially in older adults who do not have regular bowel movements or who cannot remember the last bowel movement was several weeks ago (Case Example 8-3).



Case Example 8-3


Obstipation


A 75-year-old Caucasian male was transported from his home to a hospital emergency department with acute onset of shortness of breath (SOB). He was intubated en route by ambulance personnel, secondary to hypoxemia and acute respiratory distress. Family members state that the patient has severe chronic obstructive pulmonary disorder (COPD) and uses continuous supplemental oxygen at home (usually 3 L per minute). The client had no complaints of chest pain leading up to or during the episode.


While in the hospital, the client was hypotensive and started on dopamine. Chest x-ray revealed acute pulmonary edema consistent with congestive heart failure (CHF). He was treated with intravenous Lasix. Following removal of the nasogastric (NG) tube, the client began to complain of severe low back pain and was started on Vicodin. Magnetic resonance imaging (MRI) of the lumbar/sacral spine showed multiple levels of lumbar stenosis and facet sclerosis.


Four days post hospital admission, the client’s oxygen saturation was 90% on 4 L per minute of supplemental oxygen. The decision was made to transfer the client to a skilled nursing facility (SNF) with orders for activity as tolerated and physical therapy (evaluate and treat accordingly).





Current Complaints


Client reports increased SOB with minor exertion and severe lumbar/sacral pain that has been constant over the last 3 days and appears to be getting worse.


Pain is described as “a dull ache” and is aggravated by movement. Minor relief is obtained through rest and use of pain medication. The client also reported recent lower abdominal discomfort, which he attributed to something he “ate for breakfast.”


When asked about elimination patterns, he states that his bowel movements are not regular, but he “must have had one in the hospital.” He “urinates frequently,” has trouble starting a flow of urine, and does not void completely due to an enlarged prostate.


He reports a long history of progressive back pain without traumatic onset, starting in his 40s. His immediate goal is relief of back pain. His “normal” back pain is described as a 4 to 6 on a 0 to 10 scale. His current level of intensity is described as an 8/10 on pain medication.



Review of Systems









Musculoskeletal



Evaluation: Although the client’s back pain was made worse by movement, the presence of intense pain and constitutional symptom (low-grade fever) alerted the therapist to a possible systemic or viscerogenic cause of pain. The fact that the client could not remember his last bowel movement combined with abdominal pain was of concern. Change in bladder function was also of concern.


Prior to initiation of physical therapy services, the client was referred back to the attending physician. A brief summary of the client’s neuromusculoskeletal impairments was presented, along with a description of the proposed intervention. A simple statement at the end was highlighted:





Outcome


Physician ordered a urine culture, but attempts to obtain a sample were unsuccessful. The physician was unable to insert a straight catheter, so the resident was sent to the hospital and a suprapubic catheter was inserted. He returned to the SNF 4 days later with the following diagnoses:



When the resident returned to the SNF and was seen by physical therapy, there were no complaints of low back pain (beyond his lifetime baseline) and no lower abdominal discomfort. The neurologic deficits previously identified in both lower extremities were absent.


Summary: This is a good case to point out that medical personnel occasionally miss things that a physical therapist can find when conducting a screening exam and a review of systems. Recognizing red flags sent this client back to the physician sooner rather than later and ended needless painful suffering on his part.


From Joseph R. Clemente, DPT (submitted as part of a t-DPT requirement), New York, 2003.


Keep in mind the individual who has low back pain with constipation could also be manifesting symptoms of pelvic floor muscle overactivity or spasm. In such cases, pelvic floor assessment should be a part of the screening exam. Consultation with a physical therapist skilled in this area should be considered if the primary care therapist is unable to perform this examination.


Changes in bowel habit may be a response to many other factors such as diet (decreased fluid and bulk intake), smoking, side effects of medication (especially constipation associated with opioids), acute or chronic diseases of the digestive system, extraabdominal diseases, personality, mood (depression), emotional stress, inactivity, prolonged bed rest, and lack of exercise (Table 8-1). Commonly implicated medications include narcotics, aluminum- or calcium-containing antacids (e.g., Alu-Tab, Basaljel, Tums, Rolaids), anticholinergics, tricyclic antidepressants, phenothiazines, calcium channel blockers, and iron salts.



Diets that are high in refined sugars and low in fiber discourage bowel activity. Transit time of the alimentary bolus from the mouth to the anus is influenced mainly by dietary fiber and is decreased with increased fiber intake. Additionally, motility can be decreased by emotional stress that has been correlated with personality. Constipation associated with severe depression can be improved by exercise.


People with low back pain may develop constipation as a result of muscle guarding and splinting that causes reduced bowel motility. Pressure on sacral nerves from stored fecal content may cause an aching discomfort in the sacrum, buttocks, or thighs (Case Example 8-4).



Case Example 8-4   Constipated Biker with Leg Pain


A 29-year-old male presented in the physical therapy clinic with inner thigh pain of the left leg of unknown cause over the last 3 weeks. The pain occurred most often when he had a bowel movement. He was training for an iron man competition (swimming, biking, running) but did not have any known injury or accident to attribute the symptom to.


When asked if there were any other symptoms anywhere else in his body, the client reported an inability to get an erection and a tendency toward constipation with hard stools. The therapist could find no clinical signs of muscle weakness, atrophy, or dysfunction. Postural alignment was symmetrical and without apparent problems. All provocation tests for hip, spine, sacrum, sacroiliac (SI), and pelvis were negative. The client could complete a full squat without difficulty. Hop test and heel strike were both negative.


The client was screened for signs and symptoms associated with other possible causes of erectile dysfunction such as diabetes, past history of testicular or prostate problems, past history of cancer, and possible sexual abuse. There was no red flag history or red flag signs and symptoms. Visual inspection of the lower half of the body revealed no signs of vascular compromise. The client denied any bladder problems or urinary incontinence.


Knowing that the pudendal nerve is responsible for penile erection, the therapist asked to see the client on his bicycle. Pressure on the nerve from a poorly constructed and minimally padded seat was a possible cause. The client was advised to change bike seats, change the seat height and tilt, and reassess symptoms in 2 weeks.


The client was also encouraged to stand up intermittently to relieve perineal pressure.


Result: The client reported complete cessation of all symptoms with the purchase of a bicycle seat with a cut-away middle. Since the obturator nerve passes below the symphysis pubis, it is likely bicycle seat compression on the nerve contributed to the inner thigh pain as well.


Bicycle seat neuropathy is not uncommon among long-distance bikers due to the cyclist supporting the body weight on a narrow seat. Vascular and/or neurologic compromise of the pudendal nerve is the most likely explanation for these symptoms.80,81


Because there are many specific organic causes of constipation, it is a symptom that may require further medical evaluation. It is considered a red flag symptom when clients with unexplained constipation have sudden and unaccountable changes in bowel habits or blood in the stools.



Diarrhea


Diarrhea, by definition, is an abnormal increase in stool frequency and liquidity. This may be accompanied by urgency, perianal discomfort, and fecal incontinence. The causes of diarrhea vary widely from one person to another, but food, alcohol, use of laxatives and other drugs, medication side effects, and travel may contribute to the development of diarrhea (Table 8-2).



Acute diarrhea, especially when associated with fever, cramps, and blood or pus in the stool, can accompany invasive enteric infection. Chronic diarrhea associated with weight loss is more likely to indicate neoplastic or inflammatory bowel disease. Extraintestinal manifestations such as arthritis or skin or eye lesions are often present in inflammatory bowel disease. Any of these combinations of symptoms must be reported to the physician.


Drug-induced diarrhea is associated most commonly with antibiotics. Diarrhea may occur as a direct result of antibiotic use and the GI symptom resolves when the drug is discontinued. Symptoms may also develop 6 to 8 weeks after first ingestion of an antibiotic. A more serious, less frequent antibiotic-induced colitis with severe diarrhea is caused by Clostridium difficile.


This anaerobic bacterium colonizes the colon of 5% of healthy adults and over 20% of hospitalized patients. Clients receiving enteral (tube) feedings are at higher risk for acquisition of C. difficile and associated severe diarrhea. C. difficile is the major cause of diarrhea in patients hospitalized for more than 3 days. It is spread in an oral-fecal manner and is readily transmitted from patient to patient by hospital personnel. Fastidious handwashing, use of gloves, and extremely careful cleaning of bathroom, bed linen, and associated items are helpful in decreasing transmission.12


Athletes using creatine supplements to enhance power and strength in performance may experience minor GI symptoms. Muscle cramps, diarrhea, loss of appetite, weight gain, and dizziness occur in about 8% of the individuals taking these supplements. Therapists working with athletes should keep this in mind when hearing reports of GI distress. Many sports players do not even know how much creatine they are taking or are taking more than the recommended dose. Players as young as 13 years old have reported using creatine supplements.12a,13 The use of creatine for individuals under the age of 18 is not recommended; safety and efficacy of creatine has not been established in adolescents.14


For the client describing chronic diarrhea, it may be necessary to probe further about the use of laxatives as a possible contributor to this condition. Laxative abuse contributes to the production of diarrhea and begins a vicious cycle as chronic laxative users experience excessive secretion of aldosterone and resultant edema when they attempt to stop using laxatives. This edema and increased weight forces the person to continue to rely on laxatives. The abuse of laxatives is common in the eating disorder populations (e.g., anorexia, bulimia); affected persons may ingest up to 100 laxatives at a time.


Questions about laxative use can be asked tactfully during the Core Interview (see Chapter 2) when asking about medications, including over-the-counter (OTC) drugs such as laxatives. Encourage the client to discuss bowel management without drugs at the next appointment with the physician.




Arthralgia


The relationship between “gut” inflammation and joint inflammation is well known but not fully understood. Many inflammatory GI conditions have an arthritic component affecting the joints. For example, inflammatory bowel disease (ulcerative colitis and Crohn’s disease) is often accompanied by rheumatic manifestations; peripheral joint arthritis and spondylitis with sacroiliitis are the most common of these manifestations.15,16 Sacroiliac (SI) disease without inflammation has been documented as a primary cause of lower abdominal or inguinal pain.17


There may be a genetic component between inflammatory bowel disease and ankylosing spondylitis.18 The relationship between intestinal problems and joint involvement may also be explained by some type of “interface” between the bowel and the articular surface of joints.19,20 It is hypothesized that an antigen crosses the gut mucosa and enters the joint, which sets up an immunologic response. Arthralgia with synovitis and immune-mediated joint disease may occur as a result of this immunologic response.19 It is likely that an impaired antibacterial host defense and an uncontrolled proinflammatory response of the innate immune system are at fault.21


Joint arthralgia associated with GI infection is usually asymmetric, migratory, and oligoarticular (affecting only one or two joints). This type of joint involvement is termed reactive arthritis when triggered by microbial infection such as C. difficile from the GI (and sometimes genitourinary or respiratory) tract. Other accompanying symptoms may include fever, malaise, skin rash or other skin lesions, nail bed changes (nails separate from the nail beds and become thin and discolored), iritis, or conjunctivitis.


The bowel and joint symptoms may or may not occur at the same time. Usually, this type of arthralgia is preceded 1 to 3 weeks by diarrhea, urethritis, regional enteritis (Crohn’s disease), or other bacterial infection. The knees, ankles, shoulders, wrists, elbows, and small joints of the hands and feet (listed in order of decreasing frequency) are the peripheral joints affected most often.22


A large knee effusion is a common presentation, but some clients have joint pain with minimal or no signs of inflammation. Muscle atrophy occurs when a chronic condition is present; in which case, there will be a history of previous GI and joint involvement. Stiffness, pain, tenderness, and reduced range of motion may be present, but with proper medical intervention, there is no permanent deformity.


Spondylitis with sacroiliitis may present as low back pain and morning stiffness that improves with activity and restriction of chest and spinal movement. Radiographic findings are consistent with those of classic ankylosing spondylitis with bilateral SI joint involvement and bony erosion and sclerosis of the symphysis pubis, ischial tuberosities, and iliac crests. Ultimately, “bamboo spine” (see Fig. 12-4) will result.


Inflammation involving the sites of bony insertion of tendons and ligaments termed enthesitis is a classic sign of reactive arthritis. Tendon sheaths and bursae may also become inflamed. Ligaments along the spine and SI joints and around the ankle and midfoot may also show evidence of inflammation.


Heel pain is a frequent complaint, with swelling and tenderness located either posteriorly at the Achilles tendon insertion site, or inferiorly where the plantar fascia attaches to the calcaneus. Plantar fasciitis is common. Enthesopathy can also occur around the knee, ischial tuberosities, greater femoral trochanter, and costovertebral and manubriosternal joints.23


For a more complete discussion of joint pain and how to evaluate joint pain, see Chapter 3. A list of screening questions for joint pain is also reproduced in the Appendix as a quick reference in clinical practice.



Shoulder Pain


Pain in the left shoulder (Kehr’s sign: pain with pressure placed on the upper abdomen; Danforth sign: shoulder pain with inspiration) can occur as a result of free air following laparoscopic surgery or blood in the abdominal cavity, usually from a ruptured spleen or retroperitoneal bleeding causing distention. Retroperitoneum refers to a position external or posterior to the peritoneum, the serous membrane lining the abdominopelvic walls. Retroperitoneal organs refer to viscera that lie against the posterior body wall and are covered by peritoneum on the anterior surface only (e.g., thoracic portion of the esophagus, pancreas, duodenal cap, ascending and descending colon, rectum).


The screening interview may help the client recall any precipitating trauma or injury such as a sharp blow during an athletic event, a fall, or perhaps even a minor automobile accident causing pressure from the steering wheel. The client may not connect these seemingly unrelated events with the present shoulder pain.


Perforated duodenal or gastric ulcers can leak gastric juices on the posterior wall of the stomach that irritate the diaphragm referring pain to the shoulder; although the stomach is on the left side of the body, the referral pattern is usually to the right shoulder.


A ruptured ectopic pregnancy with retroperitoneal bleeding into the abdominal cavity can also present as low abdominal and/or shoulder pain. Usually there is a history of sexual activity and missed menses in a woman of reproductive age.


Pancreatic cancer can refer pain to the shoulder and is often missed as the cause. Fluid in the pleural space as a result of pancreatitis can present as shoulder pain. When the head of the pancreas is involved, the client could have right shoulder pain, but more often it manifests as mid-back or mid-thoracic pain sometimes lateralized from the spine on either side. When the tail of the pancreas is diseased, pain can be referred to the left shoulder (see Fig. 3-4). Pain may also occur in the right shoulder when blood is present in the abdominal cavity due to liver trauma (Case Example 8-5). Accumulation of blood in this area from a slow bleed of the spleen, liver, or stomach can produce bilateral shoulder pain.



Case Example 8-5   Ruptured Spleen


A 23-year-old soccer player sustained a blow from the side as he was moving down the soccer field. He fell on his left side with the full force of his own body weight and the weight of the other player on top of him. He reported having “the wind knocked out of me” and sat out on the sidelines for 20 minutes. He resumed playing and completed the game. The next morning, he woke up with severe left shoulder pain and stopped by the office of a physical therapist located in the same building as his office. The objective examination was unremarkable for shoulder movement dysfunction, which was inconsistent with the client’s complaint of “constant pain.” The client was treated symptomatically and instructed in pendulum exercises to maintain the joint motion.


He made a follow-up appointment with the therapist for the next day, but before noon, he collapsed at work and was taken to a hospital emergency department. A diagnosis of ruptured spleen was made during emergency surgery. A ruptured spleen would have sent the typical adult for medical care much sooner, but this client was in excellent physical condition with a high tolerance for pain. Physical therapy intervention was not appropriate in this situation; an immediate medical referral was indicated given the history of trauma, sudden onset of symptoms, left shoulder pain (Kehr’s sign), and constancy of pain.



Obturator or Psoas Abscess


Abscess of the obturator or psoas muscle is a possible cause of lower abdominal pain, usually the consequence of spread of inflammation or infection from an adjacent structure. Since these muscles lie behind abdominal structures with no protective barrier, any infectious or inflammatory process affecting the abdominal or pelvic cavity can cause an obturator or psoas abscess (Figs. 8-3 and 8-4).




Psoas abscesses most commonly result from direct extension of intraabdominal infections such as diverticulitis, Crohn’s disease, pelvic inflammatory disease (PID), and appendicitis (see also the discussion on McBurney’s point later in this chapter).24 Kidney infection or abscess can also cause psoas abscess. Staphylococcus aureus (staph infection) is the most common cause of psoas abscess secondary to vertebral osteomyelitis.


Peritonitis as a result of any infectious or inflammatory process can result in psoas abscess. Besides the diseases and conditions mentioned here, peritonitis can occur as a surgical complication. Look for a history of abdominal surgery of any kind, especially the anterior approach to spinal surgery for disk removal, spinal fusion, and insertion of a cage or artificial disk implant.25 In adult women, hematogenous psoas abscesses have been observed as a complication of spontaneous vaginal delivery.26,27


Regardless of the etiology, the abscess is usually confined to the psoas fascia but can spread to the hip, upper thigh, or buttock. The iliacus muscle in the iliac fossa joins with the lower portion of the psoas muscle. Osteomyelitis of the ilium or septic arthritis of the SI joint can penetrate the muscle sheath of either muscle, producing an abscess of either the iliacus or psoas portion of the muscle.28


In addition, abscesses of the pelvis, retroperitoneal area, and abdomen can spread bacteria or fungi to local vertebral areas, causing spinal infections such as pyogenic vertebral osteomyelitis. From the lumbar spine, abscess formation may track along the psoas muscle and into the buttock (piriformis fossa), the perianal region, the groin, and even the popliteal fossa.29


Clinical manifestations of a psoas or iliacus abscess include fever; night sweats; lower abdominal, pelvic, or back pain; or pain referred to the hip, medial thigh or groin (femoral triangle area), or knee. The right side is affected most often when associated with appendicitis. Both sides can be involved with generalized peritonitis but usually that person has a clear systemic presentation and seeks medical evaluation. It is the unusual cases that a therapist will see, making it necessary to know both the typical pain patterns associated with systemic disease, as well as the atypical presentations.


Antalgic gait may develop with a psoas abscess secondary to a reflex spasm pulling the leg into internal rotation and causing a functional hip flexion contracture. The affected individual may have pain with hip extension. Often a tender mass can be palpated in the groin. The therapist must assess for TrPs of the iliopsoas muscle. A psoas minor syndrome can be mistaken for appendicitis so be sure and assess for TrPs.11


Four tests can be performed to assess the possibility of systemic origin of painful hip or thigh symptoms (Box 8-2). Gently pick up the client’s leg on the involved side and tap the heel. A painful expression and report of right lower quadrant pain may accompany peritoneal inflammation. If the client is willing and able, have him or her hop on one leg. The person with an inflamed peritoneum will clutch that side and be unable to complete the movement. The iliopsoas muscle test (Fig. 8-5) is performed when acute abdominal pain is a possible cause of hip or thigh pain. When an abscess forms on the iliopsoas muscle from an inflamed or perforated appendix or inflamed peritoneum, the iliopsoas muscle test causes pain felt in the right lower abdominal quadrant. (Pain and tenderness in the lower left side of the abdomen and pelvis may be caused by bowel perforation associated with diverticulitis, constipation, or obstipation [impaction] of the sigmoid, or appendicitis when the appendix is located on the left side of the midline.)



Box 8-2   Screening Tests for Psoas Abscess



Related posts:

Interviewing as a Screening Tool Pain Types and Viscerogenic Pain Patterns Screening the Shoulder and Upper Extremity Screening the Sacrum, Sacroiliac, and Pelvis Physical Assessment as a Screening Tool Screening for Urogenital Disease

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Mar 20, 2017 | Posted by in MANUAL THERAPIST | Comments Off on Screening for Gastrointestinal Disease

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