Osteopathic Approach To GI Complaints

Question 1

How do you determine whether an SD is primarily MSK or secondary to viscerosomatic reflex?

Answer 1

Failure of SD to respond to OMT points to viscerosomatic problem

Question 2

Pain patterns help to make a ddx in pts with GI complaints. In the GI tract, ____ ____ and ______ are found in walls of viscera and are highly sensitive to stretch, spasm, inflammation, and ischemia

Answer 2

Pacinian corpuscles; free nerve endings

Question 3

Describe visceral pathology as a result of a viscerosomatic reflex

Answer 3

Increased stretch/irritation to GI nerves —> increased afferent signals to CNS —> afferent fiber synapse in dorsal horn of spinal cord

Prolonged afferent activity leads to facilitation of the neurons and corresponding spinal segments

Visceral pathology results in somatic changes paraspinally as paravertebral TTA and increased tenderness based on increased sensitivity of segment from spinal facilitation [pattern usually reflexes to soma on side of organ]

Question 4

What is the percutaneous reflex of Morley?

Answer 4

Direct transfer of inflammatory irritation from viscera to peritoneum (not a visceral afferent reflex!)

Ex: appendicitis —> peritonitis; morley reflex responsible for abdominal wall rigidity, pain, and rebound tenderness

Question 5

Sympathetics components of GI system

Answer 5

Thoracic splanchnic n —> celiac and superior mesenteric ganglion

Lumbar splanchnic n —> inferior mesenteric ganglion

Celiac ganglion is T5-T9 = distal esophagus, stomach, proximal duodenum, liver, gallbladder, spleen, portions of pancreas

SMG is T10-11 = distal duodenum, portions of pancreas, jejunum, ascending colon, proximal 2/3 of transverse colon

IMG is T12-L2 = distal 1/3 of transverse colon, descending colon, sigmoid colon, rectum

Question 6

Parasympathetic components of GI system

Answer 6

Vagus n., pelvic splanchnic nn (S2-4)

[note anterior vagal trunk = left vagus n., posterior vagal trunk = right vagus n.]

Right vagus n. = lesser curvature of stomach, liver/gallbladder, small bowel, right colon to mid-transverse colon

Left vagus n. = greater curvature of stomach, ends at duodenum

Pelvic splanchnics = descending colon, sigmoid colon, rectum

Question 7

Possible sympathetic-related pathologies of GI tract

Answer 7

Ileus

Constipation/flatulence (increased water absorption)

Abdominal distention with hypoactive bowel sounds

Question 8

Possible parasympathetic pathologies associated with GI tract

Answer 8

Increased secretion of all GI glands

Diarrhea/fecal incontinence (decreased water absorption); hyperactive bowel sounds

Question 9

Conditions associated with GI autonomic neuropathy

Answer 9

Gastroparesis, GERD, achalasia, cyclic vomiting syndrome, IBS, reflux esophagitis, etc

Question 10

During inhalation, as the thoracic diaphragm contracts and moves _____, the pelvic diaphragm moves _____

Answer 10

Inferiorly; inferiorly

[reversed with exhalation — thoracic and pelvic diaphragm both expand and move superiorly — acts as a pump for movement of vasculature and lymphatic fluids]

Question 11

Significance of vasculature and lymphatics in the abdomen, particularly in reference to acute abdominal etiologies

Answer 11

Acute etiologies often require surgical intervention. Potentially resulting vasculature and lymphatic stasis can cause bacterial overgrowth, leading to systemic sepsis

Inflammation and infection increase metabolic process — more ILs and other cytokines

Lymphatic congestion leads to accumulation of waste, decreased medicine distribution, decreased cell nutrition, increased fibrosis/scarring, worse prognosis of IBD, bloating, cramps, reduced oxygenation

Question 12

3 large collecting intestinal nodes and where they drain

Answer 12

Celiac (drains stomach, duodenum, spleen, liver)

Superior mesenteric (drains jejunum, ileum, ascending/transverse colon)

Inferior mesenteric (drains descending/sigmoid colon, rectum)

These large intestinal nodes drain into cisterna chyli (L1-L2 area, lies on abdominal aorta) —> thoracic duct —> L subclavian v.

Question 13

What are some GI disorders influencing the metabolic energetic model?

Answer 13

Crohns

Celiac

Food sensitivity (lactose intolerance)

Sleep disorders (OSA)

Thyroid d/o

Inflammatory conditions, malabsorption d/o, inability to eliminate metabolic waste

Question 14

Metabolic changes associated with diarrhea

Answer 14

Hyperthyroidism

Hyperkalemia

Diarrhea may lead to metabolic acidosis (loss of sodium bicarb)

Question 15

Metabolic changes associated with constipation

Answer 15

Hypothyroidism

Hypercalcemia and hypokalemia

Note that geriatrics are predisposed to constipation d/t decreased physical activity

Question 16

Metabolic changes associated with vomiting

Answer 16

Metabolic alkalosis with hypokalemia (loss of HCl)

Question 17

Anti-inflammatory foods

Answer 17

Olive oil
Tomatoes
Walnuts and almonds
Spinach and kale
Salmon and mackerel
Blueberries and oranges

Question 18

OMT used to correct SDs can affect the underlying visceral functions through the ____ reflex network

Answer 18

Somatovisceral

[visceral dysfunction defined as impaired or altered mobility or motility of visceral system and related fascial, neurological, vascular, skeletal, and lymphatic elements]

Question 19

What are some signs that your OMT is complete and you should stop?

Answer 19

Relaxation of soft tissue in treated area

Altered autonomic tone has occurred

Peripheral vasodilation (increase skin temp, redness, sweating)

Increase in HR or RR

Urgency in using the restroom

Question 20

5 models OMT approach to GI pt: biomechanical

Answer 20

Postural mm, spine, extremities — posture and motion

Myofascial relationships of organs

Question 21

5 models OMT approach to GI pt: resp/circ

Answer 21

Diaphragms: thoracic inlet, thoracoabdominal, pelvic

Venous and lymphatic drainage

Question 22

5 models OMT approach to GI pt: neurologic

Answer 22

ANS homeostasis

Tx sympathetic ganglion, parasympathetic vagus n., and parasympathetic pelvic splanchnics

Question 23

5 models OMT approach to GI pt: metabolic/energetic

Answer 23

Tx other models first, taking into consideration relationships to internal organs and endocrine glands

Homeostasis, energy balance, regulatory processes, inflammation and repair, absorption of nutrients, and removal of wastes are targeted goals

Question 24

5 models OMT approach to GI pt: behavioral

Answer 24

Psychological and social activities — diet, exercise, restroom habits

Question 25

Contraindications to rib raising

Answer 25

Spinal or rib fracture

Recent spine surgery

Question 26

Contraindications to mesenteric release

Answer 26

Aortic aneurysm

Open surgical wound

Question 27

Contraindications to sacral tx

Answer 27

Local infection

Incision in area

Decubitus ulcer