Transcript Katherine Heineman, D.O. - Iowa Osteopathic Medical Association

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
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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
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Irritable bowel syndrome
Inflammatory bowel disease
Appendicitis
Diverticular disease
Kidney stones
Bladder distension
Pelvic pain
• Diffuse Abdominal Pain
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Mesenteric ischemia/infarction
Ruptured aneurysm
Abdominal wall pain
Gastroenteritis
OMT goals for the GI patient:
• Relieve, improve, and enhance the patient’s abilities
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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:
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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:
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RUQ pain had completely resolved
Bowels became much more regular
Compliant with supplement recommendation
Osteopathic structural findings:
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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:
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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
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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?