Osteopathic Considerations for the GI patient UPPER MIDWEST OSTEOPATHIC HEALTH CONFERENCE May 2, 2014 Kate 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 OMT for the GI patient: • Case Study • Concept of nociception in osteopathic medicine • Circulation • Lymphatics • Autonomics • Respiration • Mesenteries • Lab 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, Bcomplex 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 T69 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 OMT for the GI patient: • 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 OMT for the GI patient: • Case Study • Concept of nociception in osteopathic medicine • Circulation • Lymphatics • Autonomics • Respiration • Mesenteries • Lab “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 OMT for the GI patient: • Case Study • Concept of nociception in osteopathic medicine • Circulation • Lymphatics • Autonomics • Respiration • Mesenteries • Lab 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 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 OMT for the GI patient: • Case Study • Concept of nociception in osteopathic medicine • Circulation • Lymphatics • Autonomics • Respiration • Mesenteries • Lab 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 reflexes VISCERA SEGMENTAL REFLEX AREAS SYMPATHETIC Thyroid* Heart Lung Stomach Duodenum Liver Gallbladder Pancreas Small Intestine Right Colon T1-4 T1-5 T1-6 T5-9 T5-9 T5 Right T6-9 R (T9 most specific) T7 Right T10-11 T10-11 R Left Colon Appendix* Kidneys Adrenals Upper ureter Lower ureter Ovary and fallopian tube Testicle and epididymus Uterus Urinary bladder Prostate Arms Legs T12-L2 L T12 with associated rib T10-12 T10-11 T10-11 T12-L1 T10-11 T10-11 T12-L2 T12-L2 L1-2 T2-8 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 OMT for the GI patient: • Case Study • Concept of nociception in osteopathic medicine • Circulation • Lymphatics • Autonomics • Respiration • Mesenteries • Lab 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 OMT for the GI patient: • Case Study • Concept of nociception in osteopathic medicine • Circulation • Lymphatics • Autonomics • Respiration • Mesenteries • Lab 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?