GI Clinical Case Presentation Flashcards
viscerosomatic reflexes: Sympathetic Spinal Level and Facilitation Level of the Esophagus
S: T2-8/10
F: T1-6
viscerosomatic reflexes: Sympathetic Spinal Level and Facilitation Level of the Gallbladder
S: T5-9
F: T5R
viscerosomatic reflexes: Sympathetic Spinal Level and Facilitation Level of the Stomach
S: T5-9
F: T5-9L
viscerosomatic reflexes: Sympathetic Spinal Level and Facilitation Level of the Liver
S: T6-9
F: T5R
viscerosomatic reflexes: Sympathetic Spinal Level and Facilitation Level of the Spleen
S: T6-8
F: T7L
viscerosomatic reflexes: Sympathetic Spinal Level and Facilitation Level of the Pancreas
S: T6-9
F: T7R
viscerosomatic reflexes: Sympathetic Spinal Level and Facilitation Level of the Small Intestine
S: T8/9-11/12
F: T10-11
viscerosomatic reflexes: Sympathetic Spinal Level and Facilitation Level of the Appendix
S: T10
F: T12
viscerosomatic reflexes: Sympathetic Spinal Level and Facilitation Level of the Ascending, Transverse Colon
S: T10/11-L1/2
F: T10-11
viscerosomatic reflexes: Sympathetic Spinal Level and Facilitation Level of the Descending, Sigmoid Colon, Rectum
S: L1-2
F: T12-L2
Associated Ganglia: Esophagus
Celiac
Associated Ganglia: Gallbladder
Celiac
Associated Ganglia: Stomach
Celiac
Associated Ganglia: Liver
Celiac
Associated Ganglia: Spleen
Celiac
Associated Ganglia: Pancreas
Celiac
Associated Ganglia: Small Intestine
Superior mesenteric
Associated Ganglia: Ascending, Transverse Colon
Superior mesenteric
Associated Ganglia: Appendix
Superior mesenteric
Associated Ganglia: Descending, Sigmoid Colon, Rectum
Inferior mesenteric
Visceral Referred Pain Patterns: Liver, Gall bladder, duodenum
R shoulder
Visceral Referred Pain Patterns: Stomach
Post: between scapula
Ant: zyphoid and LUQ
Visceral Referred Pain Patterns Spleen
LUQ closer to mid axillary line going around to the base of the scapula
Visceral Referred Pain Patterns: Small intestine
Umbilical region
Visceral Referred Pain Patterns Sigmoid colon
Suprapubic region lateral to midline
Visceral Referred Pain Patterns Cecum and ascending colon
Suprapubic region, midline
Visceral Referred Pain Patterns: kidney and ureter
lower flank pain - ant and post
Visceral Referred Pain Patterns: appendix
Umbilical and RLQ
Visceral Referred Pain Patterns Gall bladder
RUQ costal margin wrapping around to the back
Visceral Referred Pain Patterns Liver
RUQ flank pain wrapping around the back
Visceral Referred Pain Patterns: duodenum and head of pancreas
xiphoid region midline - ant and post
Pain Referral Patterns: Acute Cholecystitis
R shoulder
Pain Referral Patterns: Cholecystitis
between midline and R nipple
Pain Referral Patterns: angina
xiphoid region
Pain Referral Patterns: splenic infarct
LUQ below lower ribs
Pain Referral Patterns: pleuritic pain
RUQ, costal margin
Pain Referral Patterns: renal colic and appendicitis
Groin area/testes in male
Keep in mind that what may be presenting as abdominal pain may have its source in _____.
the rotatores and/or multifides muscles.
“Heartburn” may be a trigger point in the _____.
external oblique muscle.
Projectile vomiting and belching can be triggered by palpation of points in the _______.
posterior abdominal wall bilaterally
Diarrhea can result from trigger points in_____which can mimic symptoms of _____.
the lower abdominal muscles …. renal pathology
Chapman’s Reflex Points: *Liver
A: R 5th and 6th intercostal space - midclavicular line to sternum
P: R Intertransverse space between T5, T6, and T7
Chapman’s Reflex Points: *Gall bladder
A: R 6th intercostal space - midclavicular line to sternum
P: R T6 - T7 intertransverse space
Chapman’s Reflex Points: Pancreas
A: R 7th intercostal space, at the costochondral junction
P: T7-T8 intertransverse space
Chapman’s Reflex Points: Small intestines
A: 8th, 9th and 10th intercostal space near cartilaginous B/L
P: L intertransverse spaces between T8-T11
Chapman’s Reflex Points: *Appendix:
A: R upper edge of rib 12 at tip
P: R intertransverse space T11-12
Chapman’s Reflex Points: Pyloric stenosis
A: Sternal body: angle of louis to xiphoid process
P: R costovertebral junction of Rib 10
Chapman’s Reflex Points: *Stomach hyperacidity
A: L 5th intercostal space: midclavicular line to sternum
P: L intertransverse space T5-6
Chapman’s Reflex Points: Stomach decreased peristalsis
A: L 6th intercostal space: midclavicular line to sternum
P: L intertransverse space T6-7
Chapman’s Reflex Points: Spleen
A: L 7th intercostal space: costochondral junction
P: L intertransverse space T7-8
*Chapman’s Reflex Points: Colon (spastic constipation or colitis)
A: B/L an area 1-2” wide, extending from the trocanter to within an inch of the patella on the front, outer aspect of the femur
P: TP of L2 – TP of L4 a triangular area reaching across to the iliac crest
*Chapman’s Reflex Points: Ant Colon (spastic constipation or colitis) R upper 1/5 indicates problem with ____.
cecum
*Chapman’s Reflex Points: Ant Colon (spastic constipation or colitis) R lower 1/5 indicates problem with the ______.
first 2/5 of transverse colon
*Chapman’s Reflex Points: Ant Colon (spastic constipation or colitis) R middle 3/5 indicates problem with _____.
ascending colon
*Chapman’s Reflex Points: Ant Colon (spastic constipation or colitis) L first 1/5 indicates problem with ______
sigmoid colon
*Chapman’s Reflex Points: Ant Colon (spastic constipation or colitis) L last 1/5 indicates problem with ______
to the last 3/5 of transverse colon
*Chapman’s Reflex Points: Ant Colon (spastic constipation or colitis) L Middle 3/5 indicates problem with ______
descending colon
*Chapman’s Reflex Points: Ant Colon (spastic constipation or colitis) L upper extreme end of the trocanter correlates with ______
recto-sigmoid junction
Chapman’s Reflex Points: Intestinal peristalsis (constipation)
A: B/L between ASIS and greater trocanter
Chapman’s Reflex Points: Rectum
A: B/L around the lesser trocanter
Chapman’s Reflex Points: Hemorrhoids, Rectum
P: B/L on the sacrum close to the ilium at the lower end of the SI jt
Chapman’s Reflex Points: Hemorrhoids
B/L just above the ischial tuberosity (anterior points)
Broad ligament and prostate Chapman points are along _____.
the lateral femur.
Sympathetic innervation is supplied by cell bodies in the ____ and fibers that terminate in the ______; these are the _____ neurons.
spinal cord …. prevertebral ganglia (celiac, superior, and inferior mesenteric ganglia)……preganglionic
Sympathetic preganglionic nerve fibers synapse with postganglionic neurons in the ganglia, and the fibers leave the ganglia and reach the end organ along ______. Rarely, there is a synapse in the ______, as seen with sympathetic innervation of other organ systems.
the major blood vessels and their branches…..paravertebral (chain) ganglia
Parasympathetic Innervation:
The vagus nerve, (CN 10th), innervates the ____(7)___.
- esophagus
- stomach
- gallbladder
- pancreas
- first part of the intestine
- cecum
- the proximal part of the colon
Parasympathetic Innervation:
The vagus exits the cranium via the ____ (along with the accessory and glossopharyngeal nerves).
jugular foramen
Parasympathetic Innervation:
The pelvic nerves innervate the ___(2)___
colon and the anorectal region
Parasympathetic Innervation:
Consistent with the typical organization of the parasympathetic nervous system, the preganglionic nerve cell bodies lie in the ____ or_____. Axons from these neurons run in the nerves to the gut (vagus and pelvic nerves, respectively), where they synapse with postganglionic neurons in ______which in this case are______.
brainstem (vagus) or the sacral spinal cord (pelvic)……..the wall of the organ, ….. enteric neurons in the gut wall.
Sympathetic or Parasympathetic?
Tends to inhibit GI function
Sympathetic
Sympathetic or Parasympathetic?
Frequently activated in pathological situations
Sympathetic
Sympathetic or Parasympathetic?
Inhibits smooth muscle
Sympathetic
Sympathetic or Parasympathetic?
Induces contraction of sphincters
Sympathetic
Sympathetic or Parasympathetic?
Regulates blood flow in the GI tract
Sympathetic
Sympathetic or Parasympathetic?
Activates physiological processes in the gut wall
Parasympathetic
Sympathetic or Parasympathetic?
Allows filling of the stomach to occur without an increase in intraluminal pressure
Parasympathetic
Sympathetic or Parasympathetic?
Generally involved in relaxation of sphincters
Parasympathetic
Sympathetic or Parasympathetic?
Contraction of smooth muscle layers in the colon
Parasympathetic
Sympathetic or Parasympathetic?
Controls the caliber of the internal anal sphincter
Parasympathetic
Sympathetically Driven Symptoms (5)
- Constipation
- Bloating
- Pain
- Contraction of sphincters
- Increased vasomotor tone (may lead to decreased mucus production in stomach and intestines)
Parasympathetically Driven Symptoms
- Nausea
- Vomiting
- Diarrhea
- Hypermotility
- Relaxation of sphincters
- Increased mucus secretion
- Increased acid production in the stomach
If increased vasomotor (sympathetic) tone leads to decreased mucus production in stomach (and/or parasympathetic activity causes increased acid production in the stomach), what is the end result?
Gastritis, Ulcers (peptic and duodenal), GERD
What is the medical treatment approach for Gastritis, Ulcers (peptic and duodenal), GERD?
Antacids, H2-blockers, PPIs, antibiotics
Why is bowel function important?
- Elimination of wastes
- Maintain homeostasis
What is Post-Operative Ileus?
- Failure to pass flatus or stool for 3/6 days after surgery
- Transient impairment of function and motility
Etiology of Post-Op Ileus (POI)
- Mechanical irritation
- Edema of tissues – mesentery and intestine
- Inflammatory molecules which cause the
- Activation of inhibitory neural reflexes
- Medications, particularly opiates
PathoPhysiology of Post-Op Ileus (POI) - Sympathetics
Sympathetic: Increased Tone
- Increased vascular tone – decreased O2 and nutrients to the tissues
- Decreased peristalsis
PathoPhysiology of Post-Op Ileus (POI) - Lymphatics
- Impaired flow increases tissue congestion
- Impaired nutrient absorption from the intestines
- Congestion increases the likelihood of fibrosis, and susceptibility to infection
The Arndt-Schultz Law
- Weak stimuli accelerate physiologic activity
- Medium stimuli inhibit physiologic activity
- Strong stimuli halt physiologic activity
What cells are considered the pacemaker cells of the gut?
Interstitial Cajal Cells (ICC)
How does visceral manipulation work?
Gut stimuli evoke digestive responses via the enteric and the central nervous systems
Cajal interstitial cells have properties of both ______.
fibroblasts and smooth muscle cells.
Visceral Sliding surfaces:
- Peritoneum
- Pericardium
- Pleura
- Meninges
Double layer system of Visceral Joints
serous fluid creates suction between surfaces of the peritoneum, etc.
Ligamentous System of the Visceral Joints
- folds of peritoneum or pleura binding an organ to the wall of the cavity or to another organ
- Not present for structural stability like skeletal ligaments
Turgor and Intracavitary pressure of Visceral Joints
hold the viscera in place, remain constant in mass, yet stick together
Mesenteric system of Visceral Joints
folds of peritoneum that support the nerves, arteries, veins and lymphatics of the small and large intestines
Omental system of Visceral Joints
folds of peritoneum that join 2 elements of the digestive tract together and has a neurovascular role
What is a visceral somatic dysfunction?
Any restriction, fixation or adhesion limits mobility and motility, along with viscerospasm and tethering (ptosis).
What causes visceral somatic dysfunctions? (6)
- Infection/inflammation
- Trauma
- Surgery
- Pregnancy
- Scoliosis/short leg syndrome
- Craniosacral dysfunction
In palpation of the abdomen, Evaluate for (4)
- Painfulness
- Differences in tension
- Position of the organ
- Tone of the organ
