Osteopathic Treatment and Clinical Application by System

Chronic pancreatitis (CP) is due to persistent inflammation, fibrosis, and irreversible cell damage to the pancreas, resulting in a loss of endocrine and exocrine gland function. Irreversible damage distinguishes CP from acute pancreatitis, in which the damage is reversible. The most common etiologies are alcohol abuse and pancreatic duct obstruction, and there is a strong association with cigarette smoking. Patients often present with recurrent epigastric abdominal pain, nausea, and features of malabsorption syndrome (diarrhea, steatorrhea, and weight loss). Characteristic computed tomography (CT) findings depend on the severity and range from mild ductal dilatation and gland enlargement to severe ductal dilatation, large cavity formations, and calcifications. Therapy focuses on alcohol cessation, diet changes, pain management, and treatment of pancreatic insufficiency. Endoscopic or surgical decompression of large ducts may be necessary, and patients who have intractable pain with small duct disease may require pancreatic resection.

Tension headache is the most common of the primary headache disorders and one of the most common disorders presenting for medical evaluation worldwide. Tension headaches are generally described as bilateral, non-throbbing, and of mild to moderate severity. There is no aura or other associated features. The diagnosis is clinical, often self-diagnosed by the patient or in the primary care setting. Management consists of abortive analgesics, such as NSAIDs and aspirin for isolated attacks, and preventative measures, such as behavioral changes, biofeedback, and preventative administration of medication for more chronic attacks.

Migraine headache is a primary headache disorder and is among the most prevalent disorders in the world. Migraine is characterized by episodic, moderate to severe headaches that may be associated with increased sensitivity to light and sound, as well as nausea and/or vomiting. A migraine attack might be preceded by a so-called aura—neurologic phenomena of visual, auditory, sensory, or motor quality. There is a strong hereditary component in the etiology of migraines. Migraine headache is a clinical diagnosis with several variants. Management strategies include abortive therapy such as NSAIDs and triptans to manage acute episodes as well as preventive strategies to minimize morbidity and pain-related disability.

Acute pancreatitis is an inflammatory disease of the pancreas due to autodigestion. Common etiologies include gallstones and excessive alcohol use. Patients typically present with epigastric pain radiating to the back. Diagnosis requires 2 of 3 criteria, including: characteristic abdominal pain, serum amylase and lipase 3 times the upper limit of normal, or characteristic radiology findings. Ranson criteria is commonly used to assess the severity. Management includes aggressive intravenous hydration, analgesia, nutritional support, and treatment of the underlying cause.

Cholecystitis is the inflammation of the gallbladder (GB) usually caused by the obstruction of the cystic duct (acute cholecystitis). Mechanical irritation by gallstones can also produce chronic GB inflammation. Cholecystitis is one of the most common complications of cholelithiasis (calculous cholecystitis) but inflammation without gallstones (acalculous cholecystitis) can occur in a minority of patients. The acute type usually presents with right upper quadrant (RUQ) pain, fever, and leukocytosis. The diagnosis is made clinically and confirmed via ultrasound (US). The definitive management is cholecystectomy, preferably performed within 72 hours. This condition can present as a mild condition or as a severe disease (with complications such as gallbladder gangrene, perforation, empyema) which require emergent intervention.

Peptic ulcers are mucosal defects > 5 mm in diameter that penetrate the muscularis mucosae in the wall of the stomach or duodenum. Peptic ulcer disease (PUD) results when exposure to acid and digestive enzymes overcomes mucosal defense mechanisms. The most common etiologies are Helicobacter pylori (H. pylori) infection and prolonged use of nonsteroidal antiinflammatory drugs (NSAIDs). Patients may be asymptomatic or present with abdominal pain, nausea, and early satiety. PUD typically responds well to medical treatment with risk factor modification, H. pylori eradication, and acid reduction. If left untreated, PUD can lead to bleeding, perforation, gastric outlet obstruction, and gastric cancer.

Gastroesophageal reflux disease (GERD) is due to pathologic reflux that causes symptoms and complications, including erosive esophagitis. Common symptoms are heartburn, early satiety, bloating, and belching. Diagnosis is made clinically and requires endoscopy in adults over 55 who are unresponsive to empiric therapy with acid blockade or those with alarm symptoms. Uncomplicated GERD can be managed with lifestyle changes and over-the-counter medications. Complications include erosive esophagitis, stricture, and Barrett esophagus, which can increase the risk of esophageal cancer. Management includes lifestyle and dietary modification, acid-reducing medications, and in some cases, surgery.

Cranial nerve palsy is a congenital or acquired dysfunction of 1 or more cranial nerves that will, in turn, lead to focal neurologic abnormalities in movement or autonomic dysfunction of its territory. Head/neck trauma, mass effect, infectious processes, and ischemia/infarction are among the many etiologies for these dysfunctions. Diagnosis is initially clinical and supported by diagnostic aids. Management includes both symptomatic measures and interventions aimed at correcting the underlying cause.

There are many etiologies of peripheral nerve injuries in the cervicothoracic region. The injuries commonly involve the phrenic nerve, the suprascapular nerve, the dorsal scapular nerve, the long thoracic nerve, or the thoracodorsal nerve. The nerves arise from the cervical plexus and brachial plexus. Causes of injury vary and may include trauma, compression, nerve entrapment, stretch or traction from repetitive movement, infection, surgical injury, or metabolic causes. Clinical presentation depends upon the motor and sensory innervation of the affected nerves. Diagnosis is mostly clinical but may also be confirmed with imaging or electrodiagnostic studies. Depending on the specific injury, management may be either surgical or conservative (physical therapy and avoidance of precipitating movements).

The ANS is a component of the peripheral nervous system that uses both afferent (sensory) and efferent (effector) neurons, which control the functioning of the internal organs and involuntary processes via connections with the CNS. The ANS consists of the sympathetic and parasympathetic nervous systems. The efferent nerve fibers that terminate in the endocrine, vascular, and visceral structures coordinate the inner workings of the body in response to several afferent inputs. The sympathetic and parasympathetic neural circuits coordinate stress responses and relaxation responses, respectively. The enteric nervous system regulates visceral organ function. A balance between these systems results in homeostasis, whereas an imbalance leads to pathological conditions.

Cerebellar disorders are a specific set of neurologic signs and symptoms caused by local or systemic conditions that affect the cerebellum; the classic sign is ataxia, in addition to several other motor abnormalities that affect coordination. The causes of cerebellar disorders range from acute alcohol intoxication to inherited conditions. Clinical presentation is with incoordination of voluntary muscle movement, affected ocular movements, speech, gait, balance, and muscle tone. The diagnosis is initially made clinically and then followed by imaging studies to determine the etiology; management depends on the specific etiology.

Vertigo is defined as the perceived sensation of rotational motion while remaining still. A very common complaint in primary care and the ER, vertigo is more frequently experienced by women and its prevalence increases with age. Vertigo is classified into peripheral or central based on its etiology. Vertigo is a clinical diagnosis, differentiated through history and physical examination findings, most notably nystagmus. Further testing may be required in malignant cases. Management depends on the etiology but certain maneuvers such as the Epley maneuver can be diagnostic and therapeutic.

Carpal tunnel syndrome (CTS) is a complex of signs and symptoms caused by compression of the median nerve as it crosses the carpal tunnel. Presentation is with pain and paresthesia of the dermatomal target tissues innervated by the median nerve as well as weakness and atrophy of the nerve's myotomal targets. Risk factors that cause a predisposition to CTS include obesity, female sex, pregnancy, diabetes, inflammatory conditions, genetic predisposition, and occupational factors. A clinical diagnosis may be made on the basis of history and physical examination and confirmed with electrodiagnostic testing. Conservative management includes splinting and physical therapy; more severe cases may require surgical correction.

Chronic pancreatitis is due to persistent inflammation, fibrosis, and irreversible cell damage to the pancreas, resulting in a loss of endocrine and exocrine gland function. The most common etiologies are alcohol abuse and pancreatic duct obstruction. Patients often present with recurrent epigastric abdominal pain, nausea, and features of malabsorption syndrome (diarrhea, steatorrhea, and weight loss). Characteristic computed tomography (CT) findings include pancreatic atrophy, dilated pancreatic ducts, and pancreatic calcifications. Therapy focuses on alcohol cessation, diet changes, pain management, and treatment of pancreatic insufficiency.

Acute pancreatitis is an inflammatory disease of the pancreas due to autodigestion. Common etiologies include gallstones and excessive alcohol use. Patients typically present with epigastric pain radiating to the back. Diagnosis requires 2 of 3 criteria, including: characteristic abdominal pain, serum amylase and lipase 3 times the upper limit of normal, or characteristic radiology findings. Ranson’s criteria is commonly used to assess the severity. Management includes aggressive intravenous (IV) hydration, analgesia, nutritional support, and treatment of the underlying cause.

Since human cells are primarily reliant on aerobic metabolism, it is of vital importance to efficiently obtain oxygen from the environment and bring it to the tissues while excreting the byproduct of cellular respiration (CO2). Respiration involves both the respiratory and circulatory systems. There are 4 processes that supply the body with O2 and dispose of CO2. The respiratory system is involved in pulmonary ventilation and external respiration, while the circulatory system is responsible for transport and internal respiration. Pulmonary ventilation (breathing) represents movement of air into and out of the lungs. External respiration, or gas exchange, is represented by the O2 and CO2 exchange between the lungs and the blood.

Laparotomy is an open surgical exploration of the abdomen, usually through a single large incision. Laparoscopy is surgical exploration and interventions performed through small incisions with a camera and long instruments. Laparoscopy offers the advantage of being minimally invasive, but it misses the tactile component of abdominal exploration for the surgeon. Both techniques have their applications, advantages, and downsides, and a surgeon should be familiar and comfortable with both techniques.

The primary lymphoid organs, also referred to as central lymphoid/lymphatic organs, are the tissues responsible for the production of lymphoid cells from progenitor cells, incuding the bone marrow and the thymus. In the bone marrow, hematopoietic stem cells progress to become oligopotent progenitors (in the case of lymphocytes, the common lymphoid progenitor). B lymphocytes stay and undergo processes for differentiation before migrating to the secondary lymphoid organs (such as lymph nodes). The progenitor cells that are to become T lymphocytes proceed to the thymus for further maturation.

The secondary lymphoid organs, also called peripheral lymphoid/lymphatic organs, include MALT, the lymph nodes, and the spleen. These collections of lymphoid tissues provide constant surveillance for pathogens. In their distinct sites, these tissues are filled with immune cells ready to mount a response when antigens are detected. Lymph nodes are seen along lymphatic vessels and occur as chains or groups (neck, groin, axillae, mesenteries, abdomen). MALTs act as immune sensors situated in locations where the lumen is exposed to the external environment (oropharynx, GI tract, genitourinary tract). The spleen is the site of production of antibodies and lymphocytes, but it also aids in the breakdown of platelets and erythrocytes.

The lymphatic system consists of the lymphoid organs containing the cells of the immune system and the lymphatic vessels, which transport interstitial fluid (as lymph) back to the venous circulation. Lymphatic vessels are spread extensively throughout the body, draining and filtering lymph, facilitating homeostasis, and aiding in defense against circulating pathogens. Fluid flow is unidirectional, enabled by valves in the collecting lymphatic vessels. In vessels without valves, the muscle contraction of organs and adjacent blood vessels help in the fluid movement. To return to the venous circulation, the lymph is collected by the major lymphatic ducts: right lymphatic duct (collects from the right side of the head and neck, the right side of the thorax, and the right upper extremity) and the thoracic duct (collects from the rest of the body). Pathologic conditions involving the lymphatic system are associated with infections, lymphatic damage, or injury and malignancies.

Tension headache is the most common of the primary primary headache disorders and one of the most common disorders presenting for medical evaluation worldwide. Tension headaches are generally described as bilateral, nonthrobbing, and of mild to moderate severity. There is no aura or other associated features. The diagnosis is clinical, often self-diagnosed by the patient or in the primary care setting. Management consists of abortive analgesics, such as NSAIDs and aspirin for isolated attacks, and preventative measures, such as behavioral changes, biofeedback, and preventative administration of medication for more chronic attacks.

Migraine headache is a primary headache disorder and is among the most prevalent disorders in the world. Migraine is characterized by episodic, moderate to severe headaches that may be associated with increased sensitivity to light and sound, as well as nausea and/or vomiting. A migraine attack might be preceded by a so-called aura—neurologic phenomena of visual, auditory, sensual, or motor quality. There is a strong hereditary component in the etiology of migraines. Migraine headache is a clinical diagnosis with several variants. Management strategies include abortive therapy such as NSAIDs and triptans to manage acute episodes as well as preventive strategies to minimize morbidity and pain-related disability.

Lungs are the main organs of the respiratory system. Lungs are paired viscera located in the thoracic cavity and are composed of spongy tissue. The primary function of the lungs is to oxygenate blood and eliminate CO2. To perform this function, the lungs need to be able to capture as much O2 as possible, a task that is easily achieved owing to their elastic morphology. Each lung is enclosed within the visceral pleura and completely fills 1 of the non-symmetrical pleural cavities, which are situated on the left and right sides of the mediastinum. The lungs encase the bronchial tree and are divided functionally and anatomically into lobes.

Gastroesophageal reflux disease (GERD) occurs when the stomach acid frequently flows back into the esophagus. This backwash (acid reflux) can irritate the lining of the esophagus, causing symptoms such as retrosternal burning pain (heartburn). This condition may eventually lead to inflammation (esophagitis), metaplasia (Barrett’s esophagus), and progression to esophageal cancer. Uncomplicated GERD can be managed with lifestyle changes and over-the-counter medications. Sometimes, however, stronger medications or surgery may be required to ease symptoms and prevent complications.

Peptic ulcer disease (PUD) refers to the full-thickness ulcerations of duodenal or gastric mucosa. The ulcerations form when exposure to acid and digestive enzymes overcomes mucosal defense mechanisms. The most common etiologies include Helicobacter pylori (H. pylori) infection and prolonged use of non-steroidal anti-inflammatory drugs (NSAIDs). Patients may be asymptomatic or may present with abdominal pain, nausea, and early satiety. Peptic ulcer disease typically responds well to medical treatment consisting of H. pylori eradication, eliminating risk factors, and proton pump inhibitors (PPIs). If left untreated, it can lead to bleeding, perforation, gastric outlet obstruction, and gastric cancer.

Cholecystitis is the inflammation of the gallbladder (GB) usually caused by the obstruction of the cystic duct (acute cholecystitis). Mechanical irritation by gallstones can also produce chronic GB inflammation. Cholecystitis is one of the most common complications of cholelithiasis (calculous cholecystitis) but inflammation without gallstones (acalculous cholecystitis) can occur in a minority of patients. The acute type usually presents with right upper quadrant (RUQ) pain, fever, and leukocytosis. The diagnosis is made clinically and confirmed via ultrasound (US). The definitive management is cholecystectomy, preferred to be performed within 72 hours. This condition can present as a mild condition or as a severe disease (with complications such as gallbladder gangrene, perforation, empyema) which require emergent intervention.

Human cells are reliant on aerobic metabolism. Obtaining O2 from the environment and transporting it to the tissues while excreting the byproduct of cellular respiration (CO2) are processes key to survival and must be closely regulated. Chemoreceptors in the lungs and tissues sense changes in the concentration of respiratory gasses and send messages to the CNS, which, in turn, modifies breathing parameters such as the respiratory rate or tidal volume to compensate for any imbalance. Disruption of this control mechanism can be caused by severe disease and also result in severe disease.