Differential Diagnosis of different Visceral System • During the examination week, being a student you feel some tension or anxiety. • Which of your system would cause disturbance in its normal process? • Which system would mostly affect by the oral medicine GIT • Digestive tract from esophagus to large intestine is lined with neuropeptides and their receptors • 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 • More than 2/3rd of all immune activity occurs in gut • GI disorders can refer pain to sternal region ,shoulder ,neck , scapular ,mid back ,lumber , hip ,pelvis and sacrum Important question • Client history , prescribed medication , associated symptoms. • Most common that resemble to MSK are ulceration or infection of mucosal lining Visceral pain • 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 corresponds to dermatomes from which the diseased organ receives its innervation . Pain is not well localized because innervation of the viscera is multi-segmental over up to eight segments of the spinal cord but with few nerve endings. • Visceral pain fibers sensitive to stretch or tension in wall of gut or neoplasm or inflammation Referred pain • Liver , diaphragm or pericardium…..C3.. C5….phrenic nerve….shoulder • Gallbladder ,stomach ,pancreas ,small intestine ……………….T 6..T9……………celiac plexus or greater splanchnic nerve……..midback or scapular region • Colon ,appendix and pelvis …mesenteric plexus or lesser splanchnic nerve …T10 T11 • Sigmoid colon rectum ……lower splanchnic nerve………..T11..L1 & S2 S4 • Lower back , sacrum , pelvis • Right shoulder referred pain ?? • Left shoulder referred pain ?? GI symptoms • Abdominal pain • Dysphagia • Odynophagia • GI bleeding (emesis, melena, red blood) • Epigastric pain with radiation to the back • Symptoms affected by food • Early satiety with weight Joss • Constipation • Diarrhea • Fecal incontinence • Arthralgia • Referred shoulder pain • Psoas abscess Dysphagia • Sensation of food catching or sticking in the esophagus • Initially with dry later on liquids • Stroke , Alzheimer , Parkinson Odynophagia • Pain during swallowing • Esophagitis or esophageal spasm • To differentiate esophagitis from coronary Ischemia: • Upright positioning relieves esophagitis pain, • Whereas cardiac pain is relieved by nitroglycerin • Both conditions require medical attention. Gastrointestinal (GI) Bleeding • Gastrointestinal bleeding can appear as mid thoracic back pain with radiation to the right upper quadrant. • Bright red blood usually represents pathology close to the rectum or anus and may be an indication of rectal fissures 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 bleeding esophageal varices, stomach, or duodenal ulceration. 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. Symptoms Affected by Food 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). The client with a duodenal ulcer may report pain during the night between midnight and 3:00 a.m. This pain should be differentiated from the nocturnal pain associated with cancer by its intensity and duration. More specifically, the pain of an ulcer may be relieved by eating, but the intense, constant and boring pain associated with cancer is not relieved by any measures. 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. • Changes in bowel habits , diet (low fibers , decrease fluid), smoking ,medication, mood etc • People with low back pain….muscle spasm decrease motility Diarrhea Diarrhea, by definition, is an abnormal increase in stool liquidity and daily stool weight associated with increased stool frequency (i.e., more than three times per day). 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 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 . Drug-induced diarrhea is associated most commonly with antibiotics Arthralgia 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. Joint arthralgia associated with gastrointestinal infection is usually asymmetric, migratory, and oligoarticular (affecting only one or two joints). This type of joint involvement is termed reactive arthritis 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. The knees, ankles, shoulders, wrists, elbows, and small joints of the hands and feet 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 Spondylitis with sacroilitis 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 sacroiliac joint involvement and bony erosion and sclerosis of the symphysis pubis, ischial tuberosities, and iliac crests. Ultimately "bamboo spine Inflammation involving the sites of bony insertion of tendons and ligaments termed enthesitis is a classic sign of reactive arthritis Heel pain is a frequent complaint, with swelling and tenderness Plantar fasciitis is common Shoulder Pain Pain in the left shoulder (Kehr's sign) can occur as result of free air or blood in the abdominal cavity such as a ruptured spleen causing distention. The Core Interview may help the client recall any precipitating trauma or injury, such as a sharp blow during an athletic event, a fall, or perhaps an automobile accident. 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. • Psoas abscesses most commonly result from direct extension of intraabdominal infections such as diverticulitis, Crohn's disease, pelvic inflammatory disease (PID), and appendicitis • Staphylococcus aureus (staph infection) is the most common cause of psoas abscess secondary to vertebral osteomyelitis. • 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. • 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 . • Antalgic gait may develop with a psoas abscess secondary to a reflex spasm pulling the leg into internal rotation 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 trigger points of the iliopsoas muscle. • A psoas minor syndrome can be mistaken for appendicitis so be sure and assess for trigger points. Iliopsoas muscle test. Palpating the iliopsoas muscle • It may be necessary to ask the client to initiate slight hip flexion to help isolate the muscle • and avoid palpating the bowel. Reproducing or causing lower quadrant, pelvic, or abdominal pain is considered a positive • sign for iliopsoas abscess Obturator muscle test • A positive test for muscle affected by peritoneal infection or • inflammation reproduces right lower quadrant abdominal or • pelvic pain. Peptic Ulcer Peptic ulcer is a loss of tissue lining the lower esophagus stomach, and duodenum. Acute lesions that do not extend through the mucosa are called erosions. Chronic ulcers involve the muscular coat, destroying musculature, and replacing it with permanent scar tissue at the site of healing. Originally, all ulcers in the upper GI tract were believed to be caused by the aggressive action of hydrochloric acid and pepsin on the mucosa. They thus became known as "peptic ulcers," which is actually a misnomer. It is now known that many of the gastric and duodenal ulcers are caused by infection with H. pylori. 10% percent of ulcers are induced by chronic use of nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen, and naproxen, commonly taken by people with arthritis H.pylori ulcers are primarily located in the lining of the duodenum (upper portion of the small intestine that connects to the stomach) NSAID-induced ulcers occur primarily in the lining of the stomach, most frequently on the posterior wall, which accounts for back pain as an associated symptom. Pain associated with duodenal ulcers is prominent when the stomach is empty, such as between meals and in the early morning. The pain may last from minutes to hours and may be relieved by antacids. Gastric ulcers are more likely to cause pain associated with the presence of food. Symptoms often appear for 3 or 4 days or weeks and then subside, reappearing weeks or months later. Back pain may be the first and only symptom. Complications of hemorrhage, perforation, and obstruction may lead to additional symptoms that the client does not relate to the back pain. Bleeding may occur when the ulcer erodes through a blood vessel. Inflammatory bowel diseases (IBD) • Unknown etiology involving genetic and immunologic influences on the GIT • Extraintestinal features: joint pains, skin lesions, uveitis, neutritional deficiencies. • Medically incurable conditions Crohn ‘s disease • Inflammatory disease that most commonly attacks the terminal end of small intestine ileum and colon. • Young adults but can appear at any age. • May present as Monoarthitis…ankle or knee. Wrist or elbow • Polyarthritis is common…Ankylosing Spondylitis • Terminal ileum involvement produces pain in the periumbilical region with possible referred pain to the corresponding segment of the low back. Pain of the ileum is intermittent and felt in the lower right quadrant with possible associated iliopsoas abscess causing hip pain. The client may experience relief of discomfort after passing stool or flatus. • it is important to ask whether low back pain is relieved after passing stool or gas. Ulcerative colitis • Inflammation & ulceration of inner lining of the large intestine(colon) & rectum(ulcerative proctitis). • Most common cause of cancer. • Rectal bleeding • Diarrhea…20 stools/day Crohn ‘s disease& Ulcerative colitis • Diarrhea • Constipation • Fever • Abdominal pain • Rectal bleeding • Night sweats • Skin lesion • Uveitis • Arthritis • Migratory Artharalgia • Hip pain(illiopsoas abscess) Irritable bowel syndrome (IBS) • “Common cold of stomach” • Functional disorder of motility in small and large intestine • Abnormal muscle contraction Sign & symptoms • • • • Painful abdominal cramps Constipation or diarrhea Nausea and vomiting Anorexia, flatulalence Colorectal cancer • 3rd most common diagnosed cancer and 2nd most common cause of death in both men and women • 40 year age • Fecal occult blood test (FOBT) Appendicitis • Appendicitis is an inflammation of the vermiform appendix that occurs most commonly in adolescents and young adults. It is a serious disease. • usually requiring surgery. When the appendix becomes obstructed, inflamed, and infected, rupture may occur, leading to peritonitis. Clinical Signs and Symptoms of Appendicitis • • • • • • • • • • • • Periumbilical and/or epigastric pain • Right lower quadrant or flank pain • Right thigh, groin, or testicular pain • Abdominal muscular rigidity • Positive McBurney's point • Rebound tenderness (peritonitis) • Positive hop test (hopping on one leg or jumping on both feet reproduces painful symptoms) • Nausea and vomiting • Anorexia • Dysuria (painful/difficult urination) • Low-grade fever McBurney's Point • The vermiform appendix and colon can refer pain to the area of sensory distribution for the eleventh thoracic nerve (Tl 1). Primary (dark red) and referred • pain patterns associated with the vermiform appendix are shown here with McBurney's point halfway between the ASIS and the umbilicus, usually on the right side. Gentle palpation of McBurney's point produces pain Rebound Tenderness or Blumberg's Sign. • A, To assess for appendicitis or generalized peritonitis, place your hand on the abdomen in an area away from the suspected area of local inflammation. Palpate deeply and slowly. • B, The palpating hand is then quickly removed. Pain induced or increased by quick withdrawal results from rapid movement of inflamed peritoneum and is called rebound tenderness. • Kehr’s sign is pain in which shoulder ? • Kehr’s sign is positive in which condition ??? • In case of hemorrhoids , the color of stool will be?? Full-figure primary pain pattern: • 1) • stomach/ duodenum; (2) liver/gallbladder/common bile duct; • (3) small intestine; (4) appendix; (5) esophagus; (6) pancreas; • and (7) large intestine/colon. Full-figure referred pain patterns • : (1) • liver/gallbladder/c ommon bile duct; (2) appendix; (3) pancreas; • (4) pancreas; (5) small intestine; (6) colon; (7) esophagus; • (8) stomach/duodenu m; (9) liver/gallbladder/c ommon • bile duct; and (10) stomach/duodenu m. Guidelines for Immediate Medical Attention • • • • • • • • • Anytime appendicitis or iliopsoas/obturator abscess is suspected (positive McBurney's test, positive iliopsoas/obturator test, positive test for rebound tenderness) • Anytime the therapist suspects retroperitoneal bleeding from an injured, damaged or ruptured spleen; ectopic pregnancy or (history of trauma; missed menses; positive Kehr's sign) Guidelines for Physician Referral • Clients who chronically rely on laxatives should be encouraged to discuss bowel management without drugs with their physician. • Joint involvement accompanied by skin or eye lesions may be reflective of inflammatory bowel disease and should be reported to the physician if the physician is unaware of these extraintestinal manifestations. • Anyone with a history of NSAID use presenting with back or shoulder pain, especially when accompanied by any of the associated signs and symptoms listed for peptic ulcer must be evaluated by a physician. • Back pain associated with meals or relieved by a bowel movement (especially if accompanied by rectal bleeding) or with back pain and abdominal abdominal pain at the same level requires medical evaluation. • Back pain of unknown cause that does not fit a musculoskeletal pattern, especially in a person with a previous history of cancer Upper & lower urinary tract • • • • Upper urinary tract…..kidneys & ureters At the level of T12 to L2 Upper portion attach with diaphragm & move with respiration • • • • Lower urinary tract…… bladder & urethra Bladder used for storage and excretion of urine • Prostate glands • Prostate carcinoma …..posterior lobe • Middle and lateral lobe……benign prostatic hypertrophy • Hyperplasia …..hypertrophy • Kidney and ureter are innervated by sympathetic and parasympathetic fibers • Renal vasoconstriction and increase rennin release associated with sympathetic stimulation • Parasympathetic innervations is derived from the Vagus nerve & the function of this innervations is not known • Renal pain • Posterior sub costal & costovertebral region • Ureteral pain • Groin area • Associated nausea , vomiting…. • Typical renal pain…..aching , dull…boring pain • Distension of capsule • Ischemia of renal tissue …..constant dull or sharp pain • • • • • Pseudo renal pain Irritation of costal nerves Traumatic history Position affects pain Prolong sitting ….. Driving • Renal pain not affected by movements • Exerting pressure increase local tenderness • Gentle percussion provoke renal pain. • • • • Referred pain If diaphragm so shoulder pain If ureter so Iliopsoas pain Mostly T10-T12 ICS classification of Urinary Incontinence Faliure to store 1. Overactive bladder Urge incontinence,elevated bladder pressure 2. Underactive outlet Stress IC, decreased outlet resistence Faliure to empty 1. Underactive bladder Decreased bladder pressure 2. Overactive outlet Increased outlet resistence COMMON TYPES OF URINARY INCONTINENCE • • • • • • • Extraurethral incontinence. Urge incontinence. Stress incontinence. Mixed incontinence Nocturnal enuresis Giggle incontinence Functional incontinence. Extraurethral incontinence • Loss of urine through channels other than the urethra is called extraurethral incontinence. • congenital abnormality . • Fistulae between the bladder or urethra and the vagina are most commonly the result of trauma at pelvic surgery such as hysterectomy, particularly where the pelvic anatomy has been distorted by disease such as endometriosis, infection or carcinoma, childbirth Urge Incontinence • • • • Definition: Involuntary leakage accompanied by or immediately preceded by urgency. Attributes: abrupt urgency with moderate to large leakage Etiology: detrussor over activity (uninhibited bladder contractions) More common in older adul Stress Incontinence • Definition: involuntary leakage on effort, exertion, sneeze or coughing. • Attributes: most common cause in young women, second most common in older women and in men or radical prostatectomy • Etiology: Intra-abdominal pressure exceeds the muscular strength of the sphincter • the internal sphincter does not close completely. • the aging process causes a general weakening of the sphincter muscles • a decrease in bladder capacity. Causes of stress incontinence, however, may differ between men and women. Mixed incontinence • Mixed incontinence is a mix of stress and urge incontinence. urine leaks with a laugh or sneeze at one time. At another time, there is sudden, uncontrollable urge to urinate just before leakage. Overflow Incontinence • Occurs when the bladder does not empty properly and leakage occurs as a result • Urine leaks and dribbles when bladder overfills. Can have urge or stress symptoms. Neurogenic detrusor overactivity • Detrusor hyperreflexia(suprasacral lesion) • Detrusor areflexia(infrasacral lesion) • Involuntary sphincter relaxation Nocturnal enuresis • is urinary incontinence during sleep, or ‘bed wetting’ at an age when a person could be expected to be dry – usually agreed to be the developmental age of 5 years. • It affects 15–20% of 5-year-old children and up to 2% of young adults. Functional incontinence • involuntary loss of urine resulting from a deficit in ability to perform toileting functions secondary to physical or mental limitations. • Rx….look first for evidence of insufficient mobility in strength and range of movement, and balance difficulties. • timed voiding • Spastic bladder • Flaccid bladder • A 50 yr old patient referred to PT for back pain, he has history of prostate carcinoma ,which part of the gland would be the target for this disease??? • A patient referred to PT for shoulder pain , during examination you observed that no MSK involvement , during system review you noted that pt has only some renal problem , do you think this can be the source of shoulder pain and how????
