OMM: Gastrointestinal Considerations

00:00 Osteopathic Considerations for the GI Tract. So, we are going to talk a little bit about how the GI system can be affected utilizing osteopathic manipulative medicine. So our GI system could present with acute and chronic problems. Having a good understanding of how osteopathic diagnosis and treatment could help treat different somatic dysfunctions could help address some of these GI problems that your patients present with. There is a relationship between the GI system and the neuroendocrine immune system and there are things that with osteopathic manipulation we could help address. Remember that there are a lot of mechanical forces that affect the GI system and also affects the digestion and function and osteopathic manipulation could affect some of the structured surrounding, the body and the GI system that could affect those mechanical forces. So, here is a look at the abdomen. When a patient presents with abdominal complaints, a lot of times we like to base our differential diagnosis on the location of the pain. So as you look at the different images here, the abdomen could be divided into 9 different quadrants or 4 quadrants and in general as you think about the different quadrants what structures lie within that area and what organs could potentially be causing pain there.

01:25 So, if a patient comes in presenting with mid epigastric pain, we have to consider possible stomach, possible aortic issues. If someone comes in with right upper quadrant pain, then that might be more liver and gallbladder. You have your small intestine that overlies the mid abdominal region. Your transverse colon also runs across the upper region. If someone comes in with right lower quadrant pain, the appendix, colon, small intestine again, potentially the kidney but the kidney is more on the flanks on both side and on the left side you think about the descending colon as it comes down into the rectum and then right above the bladder in the hypogastric region we think about possible genitourinary issue. So, when the patient comes in with different presentations of pain, location has a big factor into your differential diagnosis and you have to think about what structures are in the area. If it is in the middle of the abdomen, potentially it could be the pancreas, it could be the gut, could be the GI/GU system.

02:33 So, trying to differentiate all those different things could be challenging. So, one of the things that osteopathic manipulative medicine could allow you to do is to help you with your differential diagnosis by identifying potential viscerosomatic reflexes, either Chapman points or reflexes to the spine, and finding correlating levels and if you find those levels and find those facilitative segments you want to treat those segments first to try to decrease the facilitation and to help your patient start to improve. Some of our approach with osteopathic manipulation is to look at A for autonomics, trying to balance sympathetic and parasympathetic going to the viscera; B for breathing, trying to treat somatic dysfunctions that are affecting biomechanical restrictions that may be preventing proper respiration which then help ties in to C circulation, promoting circulatory and lymphatic drainage and flow. So, let us take a closer look at autonomics. So, sympathetic innervation to the GI system could be divided into 3 main sympathetic ganglia in the abdominal area. So, just below the xiphoid process anterior to the aorta, you could find the celiac ganglion and the celiac ganglion is associated from the levels of T5 to T9 and the greater splanchnic nerve. The celiac ganglion supplies the stomach, duodenum, liver, gallbladder, pancreas and the spleen. A little bit below that, about probably 2 to 3 inches, you will find the superior mesenteric ganglion. This ganglion is associated more with levels of T10-T11 or the lesser splanchnic nerve and the superior mesenteric ganglion supplies the small intestines below the duodenum, the right side of the colon, the kidneys, the adrenals and the gonads. Below that, you will find the inferior mesenteric ganglion. This is located anatomically close or a little slightly above the umbilicus and again anterior to the aorta and this is associated with T12 to L2, the least splanchnic nerve and the inferior mesenteric ganglion supplies the left colon and pelvic organs. So why is this important to understanding the innervation of these ganglia? The levels where it supplies can help you when you determine which ganglion could you potentially affect with OMT and so if I have a stomach issue, I may potentially try to address the structures and the celiac ganglion. If I had more of a small intestine issue, that small bowel issue, perhaps I need to address the superior mesenteric ganglion and if I have more of a lower GI distal colon issue then I might have to do treatment more surrounding the inferior mesenteric ganglion. So really understanding the different ganglion, the levels that correlate with it and what organs it supplies is an important concept to grasp. So, again this is spinal facilitation. So our sympathetic chain supplies the sympathetic innervation to the organs and T5 to T9 associated with the liver, gallbladder, duodenum and pancreas on the right side and on the left side the spleen, stomach and pancreas. So again, if we have something acutely going on we could potentially have a viscerosomatic reflex come back to these levels based on these organs. From T10-T11, again small bowel through transverse colon, the kidney, the proximal ureter, the ovaries and the testes. So, we think about the ovaries and testes to be more in the pelvic region, but the innervation comes from T10-T11 because embryologically remember the ovaries and testes actually develop first in the abdomen and then descend down into the pelvis. So, T10-T11 innervates these following structures and so if there is an acute process you might have viscerosomatic reflex back to T10-T11 and T12 to L2. So, T12 to L2 innervates the bladder, distal ureter, sigmoid colon, rectum, uterus, prostate, distal fallopian tubes. So here, again, most of the structures within the pelvis itself and more the distal portion of the GI tract. So sympathetic supply to the GI tract ultimately will decrease peristalsis, decrease glandular secretions, increase sphincter tone and reduce blood flow. So, if we think about fight or flight, the sympathetic supply being more of that trying to divert blood away from the GI tract and trying to increase all the blood supply more to your muscles, again getting ready for that fight or flight reflex. So, you are going to divert and decrease GI function when you have increased sympathetics. So, hypersympathetic tone overall will impair GI motility, decrease GI secretions, decrease blood flow to the abdominal contents, decrease oxygen supply, prolong healing time and also decrease lymphatic drainage. So, some findings and symptoms that might be associated with hypersympathetic activity include constipation, ileus, abdominal distention and flatulence. Hypersympathetic activity could be found in certain patient populations. It could be present especially in postsurgical patients.

08:15 These patients had recent surgery with incision sites that could refer and cause pain and so postsurgical patients will have hypersympathetic tone immediately after the surgery. Posttraumatic patients also have increased risk of having hypersympathetic activity. The trauma can cause also pain and discomfort and the body itself undergoing that trauma could cause hypersympathetic activity and in general all patients with systemic disease or anything where your immune system has to be activated, your body is fighting off something, it could cause increase hypersympathetic tone. So, our nociceptors are very sensitive to ischemia and inflammation. When our organs have any sort of acute event, you are going to have a signal that travels with the sympathetic nerves and facilitate reflex somatic dysfunctions. So, when we examine our patients, we could detect this viscerosomatic reflexes and based on our findings we could tell whether or not the event was an acute event or perhaps a chronic event. So, acute viscerosomatic reflexes are associated with specific findings that you would relate to like an acute process. So, the tissue will feel boggy and you will feel acute muscular changes, the area will feel warm almost even hot to touch, there may be redness present, you might have increased moisture due to the heat. This is in comparison to chronic changes and so if someone has a problem going on for more than a month to 3 months, usually acute is less than a month. Subacute is considered 1 month to 3 months. Chronic is anything greater than 3 months and what happens with chronic dysfunctions is that there are changes to the tissue itself. There is fibrosis, there is decreased blood flow and so what you might feel is more of like a thickened skin in subcu tissue. The skin actually might feel a little bit more cool and pale due to the decreased blood flow. Muscles become more hard and tense and the joints might become a little bit more stiff and firm. Chapman reflexes is another form of viscerosomatic reflex. So Dr. Chapman wrote about finding these different findings associated with organ systems and so he found that there are different points throughout the body, both anterior and posterior, that corresponded when the organs where inflamed. And so there is a whole series of Chapman points that we could identify and look for and treat when patients have some sort of visceral acute injury that may lead to a viscerosomatic reflex at those points. So when we find those points, it is important to treat the pelvis first before you actually treat the points. Dr. Chapman felt that it was helpful for lymphatics and important to treat the pelvis prior to treating the different points that he mapped out for viscerosomatics. So the points could be diagnostic, it will help you identify whether or not the problem is present and then treatment could also help to decrease facilitation.