Download Lecture 10: OMT for GI Disorders and Post

Lecture 10: OMT for GI Disorders and Post-Operative OMT Management:
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Objectives
Relate the importance of structure and function and how it relates to the GI system.
Explain the difference between and give an example of a viscerosomatic and a somatovisceral reflex.
Outline the autonomic segmental levels of the GI tract.
Explain an adjunctive osteopathic approach to a patent with the GI complaints.
Define and describe the anatomic location and visceral correlation of upper and lower GI Chapman’s points.
Identify and locate the collateral ganglia.
 Abdomen Definition
 The region of the trunk below the thoracic diaphragm
 Consists of two parts
1. Upper part – abdomen proper
2. Lower part – lesser pelvis
 These two areas are continuous at the plane of the inlet of the lesser
pelvis
 Inlet is bounded by the sacral promontory, the arcuate lines of
the innominates, pubic crests and the upper border of the
symphysis pubis.
 Functional Anatomy
 Abdomen Proper
 Superiorly: thoracoabdominal diaphragm
 Inferiorly: becomes continuous with the pelvis or the abdominopelvic portion of the abdominal cavity
 Anteriorly: abdominal muscles – rectus abdominis, pyramidales, internal/external obliques and transversus
abdominis
 Posteriorly: lower thoracic and the lumbar vertebrae, crura of the diaphragm, psoas and quadratus
lumborum muscles and posterior parts of the iliac bones
 Lesser pelvis (abdominopelvic portion)
 Superior and dorsal boundary: sacrum, coccyx, piriformis and
coccygeus muscles
 Inferior boundary: levator ani muscles and fascial coverings
(pelvic diaphragm)
 Anterolateral boundary: hip bones below the arcuate lines and
pubic crests and the obturator internus muscles
 Muscular Structures
 Anterolateral (Post muscular structures except the erector spinae)
 Rectus abdominis
 Pyramidalis
 External oblique
 Internal oblique
 Transversus abdominis
 Posterior
 Quadratus lumborum
 Psoas major/minor (40% of pt’s lack a psoas minor m.!)
 Erector spinae
 Iliacus
 Topographic Anatomy (THINK 3D!!)
 Costal Margins
 Xiphoid Process
 Iliac Crests
 Anterior superior iliac spines
 Pubic crests and tubercles
 Inguinal ligaments
 Umbilicus
 Linea alba
 Vascular Structures:
 Arteries
 Abdominal Aorta
 Celiac
 Superior mesenteric
 Renal
 Inferior mesenteric
 Veins
 Small veins and plexuses in the pelvis flow into the external and internal iliac veins
 Left and right common iliac veins
 Inferior vena cava
 Portal Venous System
 Veins collecting blood from the digestive tract, spleen, pancreas, and gallbladder join to form the portal
vein
 Carries blood to the liver
 Hepatic veins convey the blood to the inferior vena cava
 Lymphatic Structures
 Thoracic Duct
 Drains interstitial fluid from the lower extremities, the pelvic and
abdominal viscera, the left arm and the left side of the head
 Right Lymphatic Duct
 Drains interstitial fluids from the upper right section of the
trunk, right arm, and right side of the head/neck
 Where do the heart and lungs drain?
 Visceral Structures of the Abdomen
 Stomach
 Liver
 Gallbladder
 Pancreas
 Spleen
 Kidneys
 Urinary bladder
 Small intestine
 Colon
 Aorta and common iliac arteries
 Why is this important?
 Somatic dysfunctions of these muscles/skeletal structures may mimic the pain of certain abdominal disorders
 OR
 May be painful because of viscerosomatic reflex activity associated with abdominal problems
 Viscerosomatic vs. Somatovisceral Reflexes
 Viscerosomatic reflex:
 Characterized by warmth, muscle spasm, tenderness
and moisture
 Explained by physiologic process of vasodilation,
reflex stimulation of alpha motor neurons in deep
back musculature, activation of inflammatory
cascade and inflammatory mediators such as
substance P
 Numerous studies confirming (see page 896
Foundations)
 Somatic dysfunction that develops in response to
visceral pathology -> diagnostic tools!
 Somatovisceral reflex:
 Reflex patterns in visceral structures; produced by
stimulating segmentally related somatic structures
 Example: acute low back spasm causing constipation
 Percutaneous reflex of Morley
 A type of somatic pain - directly over the inflamed organ
 Produced by direct contiguous irritation of the parietal peritoneum and the abdominal wall
 Responsible for rebound tenderness and abdominal guarding associated with more severe abdominal pain
 Neurological Structures:
 Sympathetics
 Primary sympathetic fibers for innervation of all organs below the diaphragm (except descending colon and
pelvic organs) pass from cells in the thoracic spinal cord *through the thoracoabdominal diaphragm*
 Descending colon receives sympathetics from lumbar splanchnic nerves via inferior mesenteric ganglion;
pelvis receives sympathetics from sacral splanchnic nerves which arise from the sympathetic trunk
 They enter the celiac, superior mesenteric and inferior mesenteric collateral ganglia where they synapse
 Postganglionic fibers continue on to innervate specific groups of organs in the abdomen and pelvis
 Parasympathetics
 Parasympathetic innervation
 Supplied from the craniosacral outflow
 Two divisions to gastrointestinal tract
 Vagus nerve (CN X)
 Main nerve involved
 Pharynx down to splenic
flexure of the colon
 Associated with C2 and
temporal bone restrictions
 Sacral nerves S2-4 supply the
descending colon and pelvic organs
 Associated with sacral dysfunctions
 Autonomic Nerves
 Sympathetics
 Autonomic innervation comes from the splanchnic nerves
 Splanchnic nerves – situated on each side of body and formed by union of branches from T5-L1.
Greater, Lesser and Least. The superior splanchnic ends in the celiac ganglion = greater splanchnic
nerve, etc.
 Celiac ganglion – Foregut [AKA Viscerosomatic reflexes]
 Receives fibers from T5-9 via the thoracic splanchnic nerves and feeds:
 Distal esophagus
 Stomach
 Proximal duodenum
 Liver
 Gallbladder
 Spleen
 Portions of the pancreas
 Superior Mesenteric Ganglion – Midgut
 Receives fibers from T10-11 via the thoracic splanchnic nerves and feeds:
 Distal duodenum
 Portions of pancreas
 Jejunum
 Ileum
 Ascending colon
 Proximal 2/3rds of the transverse colon
 Inferior Mesenteric Ganglion – Hindgut
 Receives fibers from T12-L2 via the lumbar splanchnic nerves and feeds:
 Distal 1/3rd of the transverse colon
 Descending colon
 Sigmoid colon
 Rectum
 TART changes
 Paraspinal & spinal somatic dysfunction –> viscerosomatic reflexes
 Chapman’s Reflexes -Anterior and Posterior
 Abdominal collateral ganglia
 Autonomic Considerations
 Sympathetics
 Increased Tone
 Slows digestion
 Slows peristalsis
 Decreases enzyme release
 Vasoconstriction
 Decreased Tone
 Reverse of above
 May increase congestion of liver
 Parasympathetics
 Increased Tone
 Increases digestion
 Increases peristalsis
 Increases enzyme release
 Vasodilation
 Decreased Tone
 Slows digestion
 Spinal Reflex Levels:
 Lymphatics
 Horizontal Diaphragms
 Thoracic Inlet
 Abdominal (Thoracolumbar)
 REMEMBER, primary sympathetic fibers for innervation of all organs below the diaphragm
(except descending colon and pelvic organs) pass through
 Pelvic
 Abdominal Mesenteries
 Ascending, Transverse, Descending, Sigmoid, Diagonal
 Chapman’s Reflex Points
 A system of reflex points that present as predictable anterior and posterior fascial tissue texture abnormalities
(plaque-like changes or stringiness of the involved tissues) assumed to be reflections of visceral dysfunction or
pathology
 Reflexes are located deep to the skin and subcutaneous tissue and most often lying on the deep fascia or
periosteum
 Vary in size from pea to size of an almond
 For a CR point to be positive, both anterior and posterior points should be present
 Use the anterior points initially for diagnostic purposes as they are more widespread and then confirm by finding
the posterior CR
 Vary in tenderness from mild to almost unbearable
 Classic treatment is rotary stimulation for 20 to 60 seconds
 GI related Anterior Chapman’s Reflex points:
 GI related Posterior Chapman’s Reflex points:
 Chapman’s Reflex Points of Colon:
 Putting it all Together:
 GI system may be effected by several mechanisms
 Primary organ disease will cause viscerosomatic reflexes resulting in somatic dysfunction
 Somatic dysfunction will produce somatovisceral reflexes influencing organ irritation and dysfunction
 **Treatment of the primary organ problem will not always resolve the somatic dysfunction and so both should
be treated
 May also have viscerovisceral dysfunctions, in which case both organs should be addressed
 Treatment Goals
 Address asymmetries, motion restrictions and tissue texture abnormalities that are viscerosomatic reflections of
homeostatic disturbances
 Decrease or eliminate pain
 Remove segmental motion restrictions
 Improve altered skeletal vertebral unit and myofascial motion arising from aberrant visceral and autonomic
activity
 Decrease or eliminate segmental facilitation
 Decrease or eliminate trigger point and tender point activity
 Decrease pathophysiologic musculoskeletal and neuroreflexive factors influencing circulation
 Enhancing musculoskeletal and neuroreflexive-mediated circulatory functions
 Improve organ function
 Alter any or all of the previously mentioned situations as either contributing to, or predictive of, future health
problems
 Treatment
 Treatment of the autonomic system is aimed at the level corresponding to the innervation of the facilitated
segment
 The primary and secondary areas should be treated (e.g. gastric ulcer with medication and vagus nerve to treat
excess acid secretion)
 Sympathetic and parasympathetic levels will correspond with the organ involved
 Approaches to using OMT on the Abdomen:
1. Spinal Approach:
 Should be treated in order to improve spinal motion and ultimately restore normal nerve function in
segmentally related areas
 Numerous manipulative methods can be used
2. Peripheral Approach:
 Goal of techniques are to improve the ability to move fluids throughout the abdominal region, thus
improving the delivery of oxygen, nutrients, and arterial blood to affected areas, and facilitating venous and
lymphatic drainage for the removal of the waste products of cellular metabolism
 Thoracic/pedal lymphatic pump
 Diaphragmatic redoming
 Thoracic inlet and pelvic diaphragm releases
 Chapman reflex treatments
3. Direct Approach:
 Applied directly to the abdomen to alleviate TART changes in the abdominal wall structures
 Mesenteric Release
 Collateral Ganglia
 Post-operative complications:
1. Atelectasis
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Incomplete expansion of the lungs due to alveolar collapse
Most frequent pulmonary complication after surgery
Natural response of patient after surgery is abdominal wall splinting and shallow breathing
This prevents full diaphragmatic excursion, so alveoli at the lung bases are not expanded,
decreasing oxygen exchange in these areas
Clinical presentation:
 Low O2 saturation
 Increased respiratory rate
 Respiratory distress
 Increased respiratory secretions
 Decreased mental status
Treatments
 Incentive Spirometer
 Oxygen for hypoxemia
 CPAP for increased respiratory effort
 Mucolytics/suctioning for respiratory secretions
 Bronchodilators for bronchospasm
 OMT!
2. Ileus
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Functional inhibition of propulsive bowel motility
Thought to be due to 3 pathways
 Due to visceral sensory afferents in the splanchnic and pelvic nerves that increase inhibitory sympathetic
activity in the GI tract
 Post-operatively due to an inflammatory response from intestinal manipulation during surgery that results in
muscle dysfunction
 Inhibitory neurotransmitters such as nitric oxide and substance P slow gut motility
Clinical presentation
 Abdominal distention
 Diffuse abdominal pain
 Nausea and/or vomiting
 Inability to pass flatus or stool
 Inability to tolerate PO diet
MUST rule out mechanical small bowel obstruction, as this may require surgical intervention
 Imaging, such as KUBs or abdominal CT scans, will help differentiate between the two
Treatments
 Keep patient NPO (“nil per os” – nothing by mouth)
 Start IV fluids
 NG tube placement if persistent vomiting or abdominal distention to decompress the stomach
 Limit opioid pain medications due to constipation
 OMT!
Studies dating back to 1965 demonstrate importance and efficacy of OMT in interrupting inappropriate viscerosomaticsomatovisceral cycles
Numerous studies since which have now shown decreased hospital length of stay
 Most recent showed a decreased LOS from 11.5 days in non-OMT group to 6.1 days in OMT group!!
Wound infection
Pneumonia
Renal Failure
Peritonitis
Empyema
ARDS