osteopathic considerations for the gi patient upper midwest osteopathic health conference may 2,...

Osteopathic Considerations for the GI patient

UPPER MIDWEST OSTEOPATHIC HEALTH CONFERENCE

May 2, 2014Kate Heineman, DO and Shannon Crout DO

OMT for the GI patient:

• Case Study• Concept of nociception in osteopathic

medicine• Circulation• Lymphatics• Autonomics• Respiration• Mesenteries• Lab

DDx: • Upper Abdominal Pain• Biliary colic• GERD• Peptic ulcer disease• Non-ulcer dyspepsia• Gastritis• Hiatal hernia • Cholecystitis• Cholangitis• Pancreatitis• Pneumonia• Myocardial infarction• Splenic abscess or

infarction• Sub-diaphragmatic

abscess• Hepatitis

• Lower Abdominal Pain • Irritable bowel syndrome• Inflammatory bowel

disease• Appendicitis • Diverticular disease• Kidney stones• Bladder distension• Pelvic pain

• Diffuse Abdominal Pain• Mesenteric

ischemia/infarction• Ruptured aneurysm• Abdominal wall pain• Gastroenteritis

OMT goals for the GI patient:• Relieve, improve, and enhance the patient’s abilities• To improve circulation• To improve visceral response to stress• To relieve congestion• To enhance removal of waste products from the tissues• To improve cardiac output• To improve oxygenation and nutrition at a cellular level• To enhance resistance to infection• To enhance predictable tissue levels and the pt’s

response to medications• To enhance relaxation and comfort of the pt

• Improve circulation, improve lymphatic flow, balance autonomic activity, improve respiration

Case Study: BT• 51 y/o WF presents with biliary colic symptoms• HPI: 1-yr h/o intermittent postprandial RUQ

pain, radiation of pain to mid-back and epigastric area after meals, worse with fatty foods, intermittent diarrhea and constipation

• ROS: Denied weight loss, vomiting, hematochezia, dysuria, bowel or bladder incontinence

• Previous evaluation by general surgeon: CMP was WNL, H. pylori negative, US of RUQ was negative for findings, US of pancreas was satisfactory, CCK-HIDA scan was negative with GB ejection fraction of 97%, biliary fluid was benign

• Referral to gastroenterologist: EGD, biopsies and colonoscopy were negative for significant abnormalities

BT:• PMH: Hypothyroidism, seasonal allergies, h/o

headaches• PSH: EGD, colonoscopy• Meds: levothyroxine, Topamax, Zyrtec D,

Sudafed PRN, B-complex vitamin• Allergies: NKDA• Social Hx: Negative for tobacco, ETOH, illicit

drug use• Family Hx: Negative for colon CA, celiac disease

Physical exam:• VS: BP 110/70, P 60, R 12• General: 163-pound, healthy-appearing, WF• Neuro: CN II-XII grossly intact, +5/5 muscle

strength testing for upper and lower extremities bilaterally, +2/4 DTR for all reflexes symmetric and bilateral, no noted motor or sensory deficits

• Abdomen: Soft, NTTP, no rebound or guarding• Osteopathic structural exam: boggy tissue

texture changes at T6-9 RrSl on the right with increased fascial drag, visceral pull toward GB, motion over anterior RUQ abdominal region of the sphincter of Oddi was palpated to have counterclockwise rotation, restriction of the superior 1/3 of the linea alba, sacrum was L on R BST, L5 FRSR

Assessment/Plan:• Working diagnosis: Biliary colic NOS, biliary

dyskinesia• Treatment/plan: • OMT• ME to the thoracics and sacrum• BLT and MFR to the abdominal and lumbar regions

• Response to treatment:• Pain in the epigastric region and back was improved• T6-9 somatic dysfunction was notably improved,

although fascial drag was somewhat increased• Additional plan:• Magnesium supplementation 325 mg/day• Digestive enzymes one with each meal• Piston breathing for home exercise• F/U in 2 weeks

Follow up after 2 weeks: • RUQ pain had completely resolved• Bowels became much more regular • Compliant with supplement recommendation• Osteopathic structural findings:• Residual fascial drag T6-9 on right, no SB or R• Visceral pull to the GB much improved• Sphincter of Oddi had a clockwise rotation• L on L FST

• Treatment/Plan: • OMT using BLT and MFR to the thoracics and

abdomen and ME to the sacrum• Cont. digestive enzymes with meals for 3 months• Cont. the home piston breathing • F/U PRN


• Case Study• Concept of nociception in osteopathic medicine• Circulation• Lymphatics• Autonomics• Respiration• Mesenteries• Lab

The Concept of Nociception in Osteopathic Medicine

http://www.angelfire.com/sc3/toxchick/medpharm/medpharm57.html

Spinal outflow resulting in palpatory somatic changes

http://www.sciencedirect.com/science/article/pii/S0165017307000951

Primary Afferent Nociceptors (PANs)

http://www.nature.com/nrn/journal/v5/n7/fig_tab/nrn1431_F1.html

Facilitation of the spinal cord by PANs

http://www.studyblue.com/notes/note/n/cnspns/deck/3219889

Ward, RC. Foundations for Osteopathic Medicine, 2e, Lippincott Williams & Wilkins: 2002. Figure 8.2, pg. 139.

Sympathetic nerve supply of GB: T6-9

Ward, RC. Foundations for Osteopathic Medicine, 2e, Lippincott Williams & Wilkins: 2002. Figure 6.17, pg. 107

Allostasis:

Ward, RC. Foundations for Osteopathic Medicine, 2e, Lippincott Williams & Wilkins: 2002. Figure 8.9, pg. 152

“The rule of the artery is supreme.”• When blood and

lymphatics flow freely, the tissues can perform their physiologic functions without impedance

Abdominal Aorta• Celiac a. • Left gastric a.• Splenic a. • short gastric arteries • splenic arteries • left gastroepiploic a.

• Hepatic a. • cystic a.• R gastric a.• gastroduodenal a. • R gastroepiploic a.• superior

pancreaticoduodenal a.

• R hepatic a.• L hepatic a.

• Superior mesenteric a. • jejunal and ileal arteries• inferior

pancreaticoduodenal a.• middle colic a.• R colic a.• Ileocolic a

• anterior cecal a.• posterior cecal a. –

appendicular a.• ileal a.• colic a.

• Inferior mesenteric a. • L colic a.• sigmoid arteries• superior rectal a.

Celiac Artery

• Blood supply to:• Liver• Stomach• Abdominal esophagus• Spleen • Superior half of both

the duodenum and the pancreas

• Embryonic foregut

Superior Mesenteric Artery

•Blood supply to• Cecum • Small intestine

(except duodenum parts 1 and 2)• Ascending part of

the colon • One-half of the

transverse part of the colon

• Embryonic midgut

Inferior Mesenteric Artery

•Blood supply to • Second half of the

transverse part of the colon• Descending colon, • Sigmoid colon• Rectum

•Embryonic hindgut

Lymphatics

• Impaired lymph flow• Increased tissue congestion and impaired

nutrient absorption from the bowel• Increased likelihood of fibrosis with

increased scarring in the healing process.• Flow of lymph may be hindered by a poorly

efficient, flattened diaphragm or by torsion of the fascia around the lymphatic channels located in the mesentery or at the thoracic inlet.

Cisterna chyli

• The dilated portion of the thoracic duct at its origin in the lumbar region• Irregular

fibromuscular sac the size of a cigarette (6 cm)

Cisterna chyli

Thoracic Duct

Treatment of lymphatics• Thoracic inlet• Re-dome thoracoabdominal diaphragm• Direct or indirect fascial treatment to the

diaphragmatic attachments

• Soft tissue treatment to the paraspinal muscles and quadratus lumborum• Pectoral traction• Pelvic diaphragm through the

ischiorectal fossa.• Treat the lumbar, innominate, sacral regions

to rebalance

• Lymphatic pumps

Parasympathetic dominance• Dominates innervation of the viscera during

normal, long term, restful activity• Complaints of headaches, nausea, vomiting,

diarrhea, cramps• Stimulation will increase the secretion rate

of almost all gastrointestinal glands

Parasympathic considerations for the GI patient: CN X

• PS innervation for the upper GI tract • Exits the skull thru

jugular foramen

Vagus nerve

Ganglion nodosum

Vagus connections

Parasympathetic dominance• Complaints of headaches, nausea,

vomiting, diarrhea, cramps• Treat upper cervicals (OA, AA, C2)• Vagus nerve exits skull

• Cranial• Vagus leaves cranium through the jugular

foramen.• Suboccipital tension release• C3-5 somatic dysfunctions• Phrenic nerve to diaphragm

• Sacrum, innominates, lumbosacral dysfunctions• Pelvic splancnic nerves

• Sacral inhibition

Sympathetic considerations for the GI patient

• The spinal cord becomes facilitated from the increased and prolonged visceral afferent input• Leads to palpatory tissue changes and

tenderness to palpation in T5-11 (upper GI) or T9-L2 (lower GI) paraspinal muscles, the collateral ganglia, and Chapman’s reflex sites.• Preference for extension (small rotatores),

rotation, and sidebending to the same side as the involved organ.

Sympathetic Dominance

• Hyperactivity of the lower GI system is associated with• Ileus• Constipation• Abdominal

distension• Flatulence

Viscero-Somatic reflexesVISCERA SEGMENTAL REFLEX AREAS

SYMPATHETICThyroid* T1-4Heart T1-5Lung T1-6Stomach T5-9Duodenum T5-9Liver T5 Right Gallbladder T6-9 R (T9 most specific)Pancreas T7 RightSmall Intestine T10-11Right Colon T10-11 R

Left Colon T12-L2 LAppendix* T12 with associated ribKidneys T10-12Adrenals T10-11Upper ureter T10-11Lower ureter T12-L1Ovary and fallopian tube T10-11Testicle and epididymus T10-11Uterus T12-L2Urinary bladder T12-L2Prostate L1-2Arms T2-8Legs T11-L2

Chapman’s points• Stomach• Tender, palpable

nodules on the anterior intercostal spaces between ribs 5/6 and 6/7

• Colon• Tender, palpable

nodules on the lateral sides of the thighs in the anterior half of the iliotibial bands from the greater trochanters to the lateral epicondyles of the femurs

Rib Raising• The chain ganglia of the sympathetics lie in the fascia over

the heads of the ribs• Applied to T5-T11 • Can be administered with the patient supine, lateral

recumbent, or sitting• Position your finger pads at the rib angles• Wrists are placed onto the table such that a pressure can be

applied through the shoulders and the elbows and into the wrists

• The fingers are tractioned in a small amount in a lateral position.

• Treatment only needs to be long enough to sense palpable tissue change (a few seconds to a few minutes)

• Once a soft tissue release is appreciated, the hands are repositioned to subsequent ribs.

• One should be able to treat approximately 5-6 ribs at one time.

Ventral abdominal inhibition

Ventral abdominal inhibition

• Celiac ganglia (T5-9)• Anterior to the abdominal aorta and

between the xiphoid process and umbilicus

• Separated into a R & L ganglion• Involved in upper GI disorders (stomach,

duodenum, liver, GB, pancreas & spleen)

• Superior mesenteric ganglion (T10-11)• Located around the base of the SMA• Innervates the entire small intestine

below the duodenum, the R side of the colon, kidneys, adrenals, and gonads

• Inferior mesenteric ganglion (T12-L2)• Located around the base of the IMA• Supplies the L colon and pelvic organs

(except gonads)

Sympathetic dominance•Complaints of constipation, abdominal pain, flatulence, distention• Viscero-somatic reflexes• Chapman’s points• Rib raising• Sympathetic collateral ganglia

inhibition (celiac, superior, inferior)• Sacral rocking• Stimulates parasympathetics

Attending to mesenteries• Reduce

congestion• Improve

circulation• Free lymphatic

pathways to the small intestines

Mesentery of the Small Intestine

• Can be located in the pt by constructing an line 1 inch to the L and 1 inch above the umbilicus to a point in the RLQ just anterior to the R SI joint

OMT thoughts for the GI patient

• Improve circulatory factors• Modify fascial patterns which hinder lymphatic

patterns and pumps• Treat the base of the skull and upper cervical

areas to affect parasympathetic function• Administer rib raising and paraspinal inhibition

for autonomic imbalance and reflex dysfunction• OMT can help reduce the amount of pain

medication required for patient’s comfort and can help prepare the patient’s body for better acceptance, distribution and utilization of specific medications

References:• Canfield AJ, Hetz SP, Schriver JP, Servis HT, Hovenga TL,

Cirangle PT, Burlingame BS. Biliary dyskinesia: a study of more than 200 patients and review of the literature. J Gastrointest Surg. 1998 Sep-Oct; 2(5): 443-8.

• Singhal V, Szeto P, Norman H, Walsh N, Cagir B, VanderMeer TJ. Biliary dyskinesia: how effective is cholecystectomy? J Gastrointest Surg. 2012 Jan; 16(1): 135-40.

• Toouli J. Sphincter of Oddi motility. Br J Surg. 1984 Apr;71(4):251-6.

• Willard FH. “Ch 8: Nociception, the neuroendocrine immune system, and osteopathic medicine.” Foundations for Osteopathic Medicine by American Osteopathic Association, Ward RC, Hruby RJ, Jerome JA. Lippincott Williams & Wilkins: 2002.

• Zakko SF, Feb 2012. Uncomplicated gallstone disease. UpToDate. (April 4, 2012)

Thank you!

Questions?

osteopathic considerations for the gi patient upper midwest osteopathic health conference may 2,...

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