Gastrointestinal Pathology​ and Pharmacological Management of GI Conditions​

Signs and Symptoms of GI Disease – ​Can be seen in both in and outpatients!

• Nausea and vomiting​

• Diarrhea​

• Anorexia​

• Anorexia-cachexia ​

• Constipation​

• Dysphagia​

• Heartburn/Indigestion ​

• Abdominal pain (mechanical, inflammatory, referred)​

• GI bleeding

Rehabilitation Considerations

• Constipation as a result of

• Impaired bowel function with

• Nausea and vomiting in those on

• Many GI symptoms are not dangerous, but may make the patient

• Constipation as a result of inactivity, use of opioid medications​

• Impaired bowel function with neurological conditions​

• Nausea and vomiting in those on chemotherapy​

• Many GI symptoms are not dangerous, but may make the patient uncomfortable enough to affect participation in physical therapy

Dysphagia

• ​Neurologic conditions​

• Trauma​

• Mechanical obstruction​

  • Intrinsic​

  • Extrinsic​

• Side effect of medication

• PT Implications:

  • ​Aspiration Precautions​

  • Refer to SLP as needed

PT Implications with GI Disease​

• Fluid and electrolyte imbalance​

• Pelvic floor rehabilitation​

• Role of exercise​

• Referred pain​

  • T/L pain:

  • L shoulder pain:

• Fluid and electrolyte imbalance​

  • Increased risk for postural hypotension​

  • Watch for other signs of imbalances​

• Pelvic floor rehabilitation​

  • We can assist in the treatment of incontinence and constipation​

• Role of exercise​

  • Increased motility of GI tract​

  • Postural interventions for swallowing difficulties​

• Referred pain​

  • T/L pain: acute ulcer​

  • L shoulder pain: stomach ulcer, diverticular disease

Aging and the GI System

• Problems can start before the age of 50​

• Constipation, incontinence, diverticular disease most common​

• Age related changes:​

  • Increased risk of tooth decay​

  • Decreased taste buds​

  • Altered sense of smell​

  • Difficulty chewing/swallowing​

  • Slower absorption of nutrients​

  • Changes to the gut microbiome​

• Other pathological processes will also impact GI system​

  • Neurological changes ​

  • Diabetes

Hiatal Hernia

• Stomach comes through the

• Multiple causes​

• Symptoms​

• Treatment​

• Stomach comes through the diaphragm and into the thoracic cavity​

• Multiple causes​

  • Diaphragmatic weakness ​

  • Increased intraabdominal pressure – what factors increase?​

  • Can be congenital (for those of you interested in peds)​

• Symptoms​

  • Heartburn or reflux​

• Treatment​

  • Proton pump inhibitors to treat symptoms

Hiatal hernia- PT implications​

• Avoid playing patient flat in supine​

• Avoid Valsalva ​

• Pt ed: eliminate ETOH, quit smoking, lose weight, stress reduction

Gastroesophageal Reflux Disease (GERD)

• Lower esophageal

• H. pylori ​

  • May or may not be an association between

• Lower esophageal sphincter malfunction​

  • Gastric contents will have a backward flow into esophagus​

• H. pylori ​

  • May or may not be an association between H. pylori infections and GERD

Gastroesophageal Reflux Disease (GERD)- causes

• Food (chocolate, coffee, alcohol)​

• Smoking​

• Positioning​

• Obesity​

• Pregnancy ​

• Radiation​

• Infection​

• CNS depressants/other meds​

• Prolonged vomiting​

• Medications (beta blockers, calcium channel blockers, anticholinergics) ​

Gastroesophageal Reflux Disease (GERD)- clinical manifestations

• Heartburn**​

  • 30-60 minutes after large meal​

  • Laying flat can worsen symptoms​

• Belching​

• Dysphagia​

• Nausea​

• Vomiting​

• Painful swallowing

GERD Diagnosis and Treatment

• Endoscopy ​

• Lifestyle modifications​

• Meds (PPI)​

  • OTC and prescription​

• Surgery

Gastrointestinal Reflux Disease (GERD):​
Implications to Physical Therapy

• Timing of treatment​

• Positioning​

• Education​

  • Exercise → weight loss​

  • Swimming/biking may be better options​

  • Smoking cessation​

  • Smaller meals​

  • HOB elevated​

  • Sleeping on left side​

  • Exercise to help strengthen around esophageal sphincter​

• Osteoporosis risk with long-term medication use

Antacids- can be composed of

• Aluminum​

• Magnesium​

• Calcium carbonate​

• Sodium bicarbonate

Antacids

• Can cause ​

• Long-term use may lead to

• Need to watch timing with:​

• Can cause constipation or diarrhea depending on composition​

• Long-term use may lead to electrolyte imbalances ​

• Need to watch timing with:​

  • Warfarin (coumadin)​

  • Digoxin​

  • Iron supplements​

  • Some antibiotics

Proton Pump Inhibitors​

• Can reduce gastric secretion by 80-95%​

• May be antibacterial against H.pylori​

• Can help with ulcer healing​

• Can be used long term

• Can cause acid rebound when discontinued ​

• May be associated with adverse effects on calcium metabolism → increased fracture risk ​

• Could lead to C. difficile​

• Overall, benefits seem to outweigh the risk

• end in -zole

Esophageal Varices

• Very common in patients with

• Fragile, dilated veins in the

• _____less​

• Significant coughing up of

• Varices that rupture are a medical emergency​

  • Avoid

  • Watch for signs of

• Very common in patients with cirrhosis ​

• Fragile, dilated veins in the lower third of the esophagus ​

  • Occurs due to portal hypertension​

• Painless​

• Significant coughing up of blood​

• Varices that rupture are a medical emergency​

  • Avoid Valsalva​

  • Watch for signs of worsening liver disease

• Pathologies of the Stomach​

• Pathologies of the Intestines​

• Pathologies of the Stomach​

  • Peptic ulcer disease

• Pathologies of the Intestines​

  • Malabsorptive Disorders​

Peptic Ulcer Disease

• Erosion or ulcer of stomach or duodenum (duodenal most common)​

• Risk factors​

  • NSAID usage​

  • **H. pylori infections​

  • Crohn disease​

  • Cancer​

  • Viral infections​

  • Psychological stress and diet

Symptoms of Peptic Ulcer Disease

• Epigastric pain​

• Abdominal cramping​

• Heartburn​

• Indigestion​

• Chest pain​

• Nausea and vomiting (N + V)​

• Melena (dark stool)​

• Fatigue​

• Weight loss

Peptic Ulcer Disease and PT Implications​

• Monitor for signs of

• Referred pain​

• MSK pain

• Exercise can assist in decreasing

• Monitor for signs of bleeding​

• Referred pain​

  • Back pain​

  • Mid thoracic pain​

  • R shoulder pain​

• MSK pain (if NSAIDs are discontinued because of ulcer)​

• Exercise can assist in decreasing GI bleeding

Malabsorptive Disorders

• Celiac is one example​

• Common in Western countries​

• Patho:​

  • still a lot we don’t understand​

  • Interplay of immunity, genes, and environment​

• Symptoms:​

  • Diarrhea, bloating, weight loss, GI pain, depression, failure to thrive, delayed puberty, bone pain, multisystem involvement​

  • Nutritional deficiencies ​

  • Iron, B12 → anemia, bruising, hair loss

Malabsorptive Disorders and PT Implications

• Athletes with prolonged unexplained illness should be screened​

• Look for signs of malnutrition​

  • Fatigue, weight loss, paresthesia, muscle weakness, muscle wasting​

• Muscle spasms with electrolyte imbalances​

• Risk for osteoporosis and pathological fractures​

• Providing support as this is a life-long condition

Opioid Derivatives

• Opioids decreases

• Ex:

• Opioids decrease GI motility​

• Ex: imodium

• Side effects

  • Nausea​

  • Abdominal discomfort ​

  • Drowsiness​

  • Fatigue​

  • Risk for tolerance is small

Bismuth Salicylate

• Stimulates water and electrolyte absorption from lower GI tract​

• May limit irritation of intestinal lining​

• May be used to prevent and treat traveler’s diarrhea​

• Ex. Pepto-Bismol

• Relatively no side effects​

• May need to monitor use in those already taking aspirin (chance forOD)

Laxatives

• Categories

• Categories

  • fiber supplements

  • stool softeners

  • osmotic agents

  • lubricants

  • stimulants

• fiber supplements

  • prototypes

  • mechanism of action

• fiber supplements

  • prototypes

    • psyllium (Metamucil)​

  • mechanism of action

    • Bulk forming to facilitate passage of stool through rectum

• stool softeners

  • prototypes

  • mechanism of action

• stool softeners

  • prototypes

    • Docusate (Colace)

  • mechanism of action

    • Facilitates movement of water and fats into stool

• osmotic agents

  • prototypes

  • mechanism of action

• osmotic agents

  • prototypes

    • Milk of Magnesia; polyethylene glycol (PEG) 3350 (Miralax)

  • mechanism of action

    • Causes water to be retained with the stool, increasing the number of bowel movements and softening the stool so it is easier to pass

• lubricants

  • prototypes

  • mechanism of action

• lubricants

  • prototypes

    • mineral oil enema (Fleet)

  • mechanism of action

    • Coats the stool to help seal in water

• stimulants

  • prototypes

  • mechanism of action

• stimulants

  • prototypes

    • Bisacodyl (Dulcolax)

  • mechanism of action

    • Causes the intestines to contract, inducing stool to move through the colon​

laxatives side effects

• Nausea​

• Cramps​

• GI irritation​

• Fluid and electrolyte imbalances​

• Dehydration​

• Can be life threatening in those with cardiac or renal conditions​

• Can develop tolerance

Vascular Diseases: Intestinal ischemia​ (Decreased blood supply to intestines)​

Acute mesenteric ischemia:

• Decreased blood supply to ​

• >

• Occlusion of blood flow – usually a

• Present with

• Diagnosis via

• _________ treatment needed

• Decreased blood supply to intestines ​

• >60 years old; a-fib; CAD; heart failure​

• Occlusion of blood flow – usually a thrombosis on an already compromised vessel​

• Present with abdominal pain progressing to N + V, fever, mental status changes, black pain ​

• Diagnosis via CT scan​

• Surgical treatment needed

Vascular Diseases: Intestinal ischemia​ (Decreased blood supply to intestines)​

Chronic mesenteric ischemia:

• Secondary to

• Pain after

• Diagnosis via

• Can be treated with

• Secondary to atherosclerosis ​

• Pain after eating (60 minutes)​

• Diagnosis via CT scan​

• Can be treated with bypass surgery

Abdominal Surgical Approaches​

• Laparoscopy

• Laparotomy

• Laparoscopy

  • Laparoscopy is a minimally invasive surgical procedure which sometimes referred as keyhole surgery as it uses a small incision

• Laparotomy

  • Laparotomy is basically a surgical procedure which involves a large incision in the abdomen to facilitate a procedure.

Inflammatory Bowel Disease (IBD)​

• Crohn’s disease

• Ulcerative colitis

IBD Pathophysiology​

• Much is still

• Gut

• _______ risk​

• Increased inflammatory

• Much is still unknown​

• Gut microbiota, host immunity, intestinal mucosal response​

• Genetic risk​

• Increased inflammatory cytokines​

  • Lesions, ulcerations, erosions

Crohn’s disease and ulcerative colitis:

• are two distinct diagnoses, but have similar

• crohn’s typically has more

• ulcerative colitis typically has more

• are two distinct diagnoses, but have similar symptoms

• crohn’s typically has more systemic effects

• ulcerative colitis typically has more GI affects

IBD- diagnosis and treatment

• diagnosis

  • Colonoscopy and biopsy​

  • Endoscopy

• treatment

  • Pharmacological management (5-ASAdrugs, others)​

  • Nutritional support and dietarymanagement​

  • Severe disease may need glucocorticoids ​

  • Colectomy ​

  • Watch for signs of colorectal cancer

IBD- Physical Therapy Implications​

• Musculoskeletal​

  • Referred pain to back​

  • Psoas abscess (look for signs of infection)​

  • Arthralgias ​

• Medication use​

  • Corticosteroids ​

  • Link to osteoporosis​

• Signs of malnutrition and dehydration​

• Psychologic issues

Diverticular Disease

• Diverticulosis​

• Diverticulitis​

  • progression of diverticulosis

• Common in western cultures​

  • Due to low-fiber diets​

Diverticular Disease: Risk Factors​

• Obesity​

• Chronic constipation​

• Heredity​

• Diet ​

• Sedentary lifestyle​

• Medications​

• Age​

• Congenital alterations in intestinal wall structure

Diverticular Disease: Signs and Symptoms

• Asymptomatic in majority of cases​

• Symptoms​

  • L quadrant pain (increased with eating)​

  • Fever​

  • Bowel changes​

  • Nausea, vomiting​

  • May also experience urinary issues​

    • higher risk of UTI if constipated or have diarrhea

Diverticular Disease: PT Implications

• Screening​

  • Screening for

• Referring​

  • Referring back to

• Establishing​

• Screening​

  • Screening for those with back pain of unknown origin​

• Referring​

  • Referring back to MD if fever​

• Establishing​

  • Establishing exercise program​

    • Physical activity is protective​

    • Avoid increasing intraabdominal pressure

Colorectal cancer -Adenocarcinoma

• Many without predisposing factors will be diagnosed ​

• Risk factors:​

  • >40​

  • Male​

  • Personal history of UC or CD​

  • History of polyps​

  • Family history of colon cancer​

  • Obesity ​

  • ? Smoking and excessive ETOH​

  • Diet low in fiber

Colorectal cancer: Clinical Signs

• Few early warning signs​

• Change in bowel habits​

• BRBPR (bright red blood per rectum)​

• Complications include:​

  • Obstruction​

  • Bleeding​

  • Perforation​

  • Anemia​

  • Ascites​

  • Metastases (liver (RUQ pain), lungs, bone, brain)

Cancer staging

• T =

• N =

• M =

• stage IV =

• T = tumor

• N = lymph nodes

• M = metastasis

• stage IV = metastatic disease

Colorectal cancer: treatment

• Surgical removal ​

  • Bowel resection​

  • Tumor removal​

  • Lymph node removal ​

• Chemo (neoadjuvant prior to surgery,adjuvant following surgery)​

• Targeted biologic therapy

PT Implications for Colon Cancer

• Adaptive shortening of abdominal musculature​

• Lymphedema risk with lymph node removal ​

• Anemia with intestinal bleeding​

• Mobility following surgery​

• Deconditioning and exercise ​

• Lumbar pain ​

• Pelvic floor rehabilitation​

• Also play a role in prevention​

  • Encourage screening for those at risk​

    • Those aged 45 to 75​

    • Stool test vs. colonoscopy

Common GI Issues: Seen in both in- and outpatients

• Diarrhea​

• Constipation​

• Nausea and vomiting​

• Infections