Upper GI SystemUpper GI SystemOsteopathic Manipulative Osteopathic Manipulative

MedicineMedicine

ObjectivesObjectives• Review previously learned concepts and

techniques which apply to diagnosis and treatment of upper gastrointestinal disorders

• Identify patterns of viscerosomatic reflexes which correspond to disease processes in individual organs

• Incorporate somatic findings in the diagnosis and treatment of upper GI disorders

Viscerosomatic ReflexesViscerosomatic Reflexes

• DiGiovanna/Schiowitz – T5-6R - upper esophagus– T6-9R - liver and gall bladder– T8-9B - small intestine– T5-9L - lower esophagus and stomach– T6-9L - spleen and pancreas

• Musculoskeletal pain related to visceral dysfunction may be the sole presenting symptom of viscerosomatic reflex

TechniquesTechniques

• Thoracic Techniques - Sympathetics– HVLA– Muscle Energy– Counterstrain– Soft tissue

• Lymphatic Techniques

• Cranial & Cervicals - Parasympathetics – Vagus (Cranial nerve 10)

FasciaFascia

• “Fascia directly or indirectly influences the health of the body through coordination with the musculoskeletal system, cooperation in circulating body fluids, and by allowing generous passageway for nerves. Derangement in the fascial planes can result in veinous congestion, abnormal reflexes, and a decreased range of motion. Thus myofascial techniques are crucial in eliminating fascial restrictions and allowing the body to return to a healthier state.” -DiGiovanna

Myofascial TechniquesMyofascial Techniques

• Motion Testing

• Take tissues into ease of motion

• Tissues Release

• Retest

• Take tissues into ease of motion

• Continue until motion is free

Chapman’s ReflexesChapman’s Reflexes

• myofascial tender points related to specific visceral dysfunction

• helpful in diagnosis• anterior points more

helpful - more tender• firm gentle contact

with rotary motion to dissipate the swelling

True visceral painTrue visceral pain• pacinian corpuscles• free nerve endings• activated by spasm or

stretch• carried by visceral

afferents• midline pain, poorly

localized-vague, deep, diffuse, burning ache

Viscerosomatic PainViscerosomatic Pain

• pain receptors in anterior and lateral parietal peritoneum, lesser omentum, mesentaery, mesocolon

• facilitated cord segments in somatic areas related to the viscera’s sympathetic innervation

Viscerosomatic ReflexesViscerosomatic Reflexes

• alerts clinician to look for visceral cause

• HVLA is often ineffective - met with a rubbery resistance

SympatheticsSympathetics

• rapid and widespread organ and somatic changes required to meet stress (flight/fight)

• activation of one sympathetic fiber produces 4 to 40 post ganglionic fiber activations

ParasympatheticsParasympathetics

• dominate innervation during restful activity

• Vagus, CN X, exits via jugular foramen– left - greater curvature of stomach, duodenum– right - lesser curvature, small intestines, right

colon, and organs and glands up to midtransverse colon

• stimulation will increase secretion rate of most glands

LymphaticsLymphatics

• flow of lymph may be hindered by poorly efficient, flattened diaphragm, torsion of the fascias around the lymphatic channels

• slight impedance of lymphatic pathways or hindrance to the function of the diaphragm can reduce the body’s ability to recover from a disease process

Somatic systemSomatic system

• somatic pain may persist even after the visceral problem has resolved

• treatment is OMT

• examples:– Peptic ulcer disease– Postcholecystectomy syndrome

Treatment of Upper GI Treatment of Upper GI disordersdisorders

• Osteopathic treatment is directed toward improving the physiologic function of the patient

• Treatment will– reduce need for pain medication– balance autonomic activity– improve lymphatic flow

Goals of OMTGoals of OMT

• improve visceral response to stress• relieve congestion• improve circulation• enhance removal of waste products • improve cardiac output• improve oxygenation and nutrition (cellular)• enhance medication effectiveness• relaxation and comfort - diagnosis/treatment

TreatmentTreatmentLymphatics and FasciasLymphatics and Fascias

• Mesenteric lift (small intestines) - frees lymphatic pathways - lift upward and to right side of abdomen - respiratory cooperation

• Visceral manipulation of individual viscera

• Doming of diaphragm

• Lymphatic pump techniques

Visceral ManipulationVisceral ManipulationBasic TenetsBasic Tenets

• an organ or viscera in good health has physiologic motion– mobility - voluntary or diaphragmatic – motility - inherent motion

• restriction implies functional impairment

• motion repeated thousands of times daily can bring about significant changes to organ and adjacent structures

Upper GI System Upper GI System Osteopathic Clinical ExamplesOsteopathic Clinical Examples

• Diaphragm restriction in GERD

• Midscapular pain treated with NSAIDS may actually be referred viscerosomatic pain