Gastrointestinal System

Dr Kaneez Sadia; PT
The University of Faisalabad
Date: 12-11-2018
 Learning objectives

A basic understanding of the structure and

function of the GIT system

Information on the clinical evaluation of the GI

system, including physical examination and
diagnostic studies

A basic understanding of the various diseases

and disorders of the GIt system
 Learning objectives

Information on the management of GIT

disorders , including pharmacologic therapy
and surgical procedure

Guidelines for physical therapy intervention in

patients with GI diseases and disorders
Structure and function
 Clinical evaluation
• Evaluation of the GI system involves
combining information gathered through
physical examination and diagnostic studies.
 Physical examination
• Physical examination of the abdomen consists
of inspection, auscultation, percussion, and
palpation.
• Physicians and nurses usually perform this
examination on a daily basis in the acute care
setting; however, physical therapists can also
perform this examination to help delineate
between systemic and musculoskeletal pain.
 History
• Before performing the physical examination,
the presence or absence of Items related to GI
pathology is ascertained through patient
interview, questionnaire complétion , or chart
review.
 Items associated with gastrointestinal
pathology
Sign and symptoms Stool and urine Associated disorders
characteristics

1. Nausea and vomiting 1. Change In stool color 1. History of hernia

2. Hemoptysis 2. Change in urine color 2. History of hepatitis
3. Constipation 3. Hematochezia (bright 3. Drug and alcohol
4. Diarrhea 4. red blood in stool) 4. abuse
5. Jaundice 5. Melena (black, tarry 5. Fatty food intolerance
6. Heartburn 6. stools)
7. Abdominal pain
 Inspection
• During inspection, the physical therapist
should note asymmetries in size and shape in
each quadrant, umbilicus appearance, and
presence of abdominal scars indicative of
previous abdominal procedures or trauma.
• The presence of incisions, tubes, and drains
should also be noted during inspection,
because these may require particular handling
or placement during mobility exercises.
 Auscultation
• The abdomen is auscultated for the presence or
absence of bowel sounds and bruits (murmurs) to
help evaluate:
1. gastric motility
2. vascular flow
• Bowel sounds can be altered postoperatively, as well
as in cases of diarrhea, intestinal obstruction,
paralytic ileus, and peritonitis.
• The presence of bruits may be indicative of renal
artery stenosis.
 Percussion
• Mediate percussion is used to evaluate liver
and spleen size and borders, as well as to
identify ascetic fluid, solid- or fluid-filled
masses, and air in the stomach and bowel.
 Palpation
• Light palpation and deep palpation are used to identify
1. Abdominal tenderness
2. Muscular resistance
3. Superficial organs and masses.
• The presence of rebound tenderness (i.e., abdominal pain
worsened by a quick release of palpatory pressure) is an
indication of peritoneal irritation from possible abdominal
hemorrhage and requires immediate medical attention.
• Muscle guarding during palpation may also indicate a
protective mechanism for underlying visceral pathology.
 Diagnostic Studies
• Diagnostic evaluation for the GI system will be
• divided into
1. Examination of the GI tract
2. Examination of the hepatic, biliary,
pancreatic, and splenic systems.
3. Examination of the GI tract includes the
esophagus, stomach, and the intestines
(small and large).
 Diagnostic Studies
• Carcinoembryonic antigen (CEA)
• D-Xylose absorption test (xylose tolerance
test, xyloseabsorption test)
• Gastric stimulation test (tube gastric analysis,
pemagastrinstimulation test, gastric acid
srimulacion test)
• Basal acid output
• Peak acid Output
 Diagnostic Studies
• Gastrin
• Helicobacter pylori tests
• Serologic test
• Urea breath test
• Tissue biopsy
• 5-Hydroxyindoleacetic acid (5-HlAA)
• Lactose tolerance test (oral lactose tolerance test)
• Occult blood (fecal occult blood test, FOBT, FOB)
• Serotonin (5-hyclroxytryptamine)
 Diagnostic Studies
• Hepatocellular injury results in cellular
damage in the liver, which causes increased
levels of the following enzymes:
1. Aspartate -amino-transferase
2. Alanine aminotransferase
3. Lactate dehydrogenase.4
 Diagnostic Studies
• Hepatocellular dysfunction can be identified
when bilirubin levels are elevated or when
clotting times are increased (denoted by an
increased prothrombin time).
• The liver produces clotting facTors and,
therefore, an increased prothrombin time
implicates impaired production of coagulation
facrors.
 Diagnostic Studies
• Cholestasis is the impairment of bile flow from
the liver to the duodenum and results in
elevations of the following serum enzymes:
1. Alkaline phosphatase
2. Aspartate transaminase
 Laboratory tests
• Barium enema (BE)
• Barium swallow (esophagography)
• Colonoscopy (lower pan-endoscopy)
• Computed Tomography of the GI Tract
• Esophageal manometry
• Esophageal acidity test (Tuttle test)
• Acid perfusion test (Bernstein test)
• Gallium scan (gallium 67 imaging, total body
• scan)
 Pathophysiology
• GI disorders can be classified regionally by the
structure involved and may consist of the
following:
1. Motility disorders
2. Inflammation or hemorrhage
3. Enzymatic dysfunction
4. Neoplasm's
 Esophageal Disorders
• Dysphagia
• Motility Disorders and Angina-Like Chest Pain
• Achalasia
• Diffuse esophageal spasm
• Gastroesophageal Reflux Disease
• Barrett's Esophagus
• Esophageal Varices
• Esophageal Cancer
 Stomach Disorders
• Gastrointestinal Hemorrhage
• Gastritis
• Peptic Ulcer Disease
• Gastric Ulcer
• Duodenal Ulcer
• Zollinger-Ellison Syndrome
• Gastric Emptying Disorders
• Gastric Cancer
 Intestinal Disorders
• Appendicitis
• Diverticular Disease
• Hernia
• lntestinal Obstructions
• Intestinal Ischemia
• Irritable Bowel Syndrome
• Malabsorption Syndromes
• Peritonitis
• Crohn's Disease
 Intestinal Disorders
• Ulcerative Colitis
• Polyps
• Intestinal Tumors
 Anorectal Disorders
1. Hemorrhoids
2. Ano-rectal fistula
3. Anal fissure
4. Imperforate anus
5. Rectal prolapse.
 Liver and Biliary Disorders
• Hepatitis
• Cirrhosis
• Hepatic Encephalopathy and Coma
• Cholecystitis with Cholelithiasis
 Pancreatic Disorders
• Pancreatitis
 Management
• Pharmacologic Therapy
• Surgical Procedures
 Physical Therapy Intervention
• PT Goals
1. To optimize functional mobility
2. To maximize activity tolerance and endurance
3. To prevent postoperative pulmonary
complications
 Guidelines for Physical Therapy
Intervention
• Patients with GIT dysfunction can have
increased fatigue levels as a result of poor
nutritional status from malabsorption and
anemia from inflammatory and hemorrhagic
conditions of the GI tract. Therefore, consider
the patient's fatigue level with treatment
planning and setting of goals.
 Guidelines for Physical Therapy
Intervention
• Consultation with the nutritionist is helpful in
gauging the appropriate activity prescription,
which is based on the patient's caloric intake.
It is difficult to improve the patient's strength
or endurance if his or her caloric intake is
insufficient for the energy requirements of
exercise.
 Guidelines for Physical Therapy
Intervention
• Reviewing the patient's laboratory values to
determine hematocrit and hemoglobin levels
before treatment may be helpful in planning
the patient's activity level for that session
 Guidelines for Physical Therapy
Intervention
• Malabsorption syndromes can also lead to
altered metabolism of medications and,
therefore, the responses to medications will
be less predictable and can impact the
treatment planning of the therapist
 Guidelines for Physical Therapy
Intervention
• Patients with GI dysfunction may have certain
positioning precautions.
a)Dysphasia can be exacerbated in supine positions and
may also lead to aspiration pneumonia.
b) Portal hypertension can be exacerbated in the supine
position because of gravitational effects on venous
flow.
c) If the patient has associated esophageal varices from
portal hypertension, then the risk of variceal rupture
may be increased in this position as well.
 Guidelines for Physical Therapy
Intervention
d)Patients with portal hypertension and
esophageal varices should also avoid
maneuvers that create a Valsalva effect, such
as coughing.
e) The increase in intra-abdominal pressure from
Valsalva's maneuvers can further exacerbate
the esophageal varices. (Huffing, instead of
coughing, may be more beneficial in these
situations.)
 Guidelines for Physical Therapy
Intervention
• Non-pharmacologic pain management techniques
from the physical therapist may benefit patients
who have concurrent diagnoses of rheumatologic
disorders and GI dysfunction.
• NSAlDs are a causative risk factor for many
inflammatory and hemorrhagic conditions of the GI
system
• Rheumatologic conditions may have limitations in
functional mobility as a result of altered pain
management.
 Guidelines for Physical Therapy
Intervention
• Patients with ascites or large abdominal
incisions are at risk for pulmonary
complications.
• Ascites and surgical incisions create
ventilatory restrictions for the patient.
 Guidelines for Physical Therapy
Intervention
• Effective pain management before physical
therapy intervention, along with diligent
position changes, instruction on incisional
splinting during deep breathing and coughing,
and early mobilization with or without
assistive devices, will help prevent the
development of pulmonary complications and
deconditioning.