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115 Cards in this Set
- Front
- Back
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What causes coffee ground emesis?
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ulcers
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What is the chapman point for esophageal varices?
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2nd ICS
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What is the chapman point for the appendix?
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tip of the right 12th rib
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Dysfunction in which organs would cause substernal pain?
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esophagus = GERD
heart = MI |
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Dysfunction in which organs would cause RUQ pain?
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duodenum
liver gallbladder hepatic flexure (colon) |
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Dysfunction in which organs would cause epigastric pain?
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stomach
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Dysfunction in which organs would cause upper abdominal pain?
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pancreas
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Dysfunction in which organs would cause peri-umbilical pain?
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small intestine
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Dysfunction in which organs would cause LUQ pain?
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Splenic flexure (colon)
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Dysfunction in which organs would cause RLQ pain?
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Appendix, Cecum
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Dysfunction in which organs would cause LLQ pain?
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Sigmoid, Rectum
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Which organ would cause generalized upper abdominal pain?
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the pancreas
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What are the characteristics of true visceral pain?
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early pain from irritation, stretching, contraction of exaggerated physiologic motor activity and dysfunction
Midline pain (may be right or left depending on the organ), poorly localized and described as vague, deep, diffuse burning ache |
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What are the characteristics of viscerosomatic pain?
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facilitated cord segments causing hypersympathicotonia in somatic areas related to the viscera's sympathetic innervation
well localized, asymmetric, aggravated by jarring motions may be added to the visceral pain pattern or overwhelm and mask it |
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Percutaneous Reflex of Morley
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Direct transfer of inflammatory irritation from the viscera to the parietal peritoneum and abdominal wall without reflex through the visceral afferent nerve on a somatic afferent near the mesentary. It produces abdominal wall rigidity, pain, and rebound tenderness
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Phrenic pain
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referred to C3-5
occurs when either the hemidiaphragm or Glisson's capsule of the liver is stimulated |
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Paraspinal somatic dysfunction at T5-9 includes veiscero-somatic reflexes from which organs?
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Stomach
Liver Gallbladder Duodenum Pancreas |
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Paraspinal somatic dysfunction at T10-11 includes veiscero-somatic reflexes from which organs?
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small intestine
ascending and transverse colon |
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Paraspinal somatic dysfunction at T12-L2 includes veiscero-somatic reflexes from which organs?
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Transverse and descending colon
sigmoid colon rectum |
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What makes up the foregut?
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distal esophagus
stomach proximal duodenum liver gall bladder spleen pancreas (head) |
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What makes up the midgut?
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distal duodenum
pancreas (tail) jejunum ileum ascending colon proximal 2/3 of the transverse colon |
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What makes up the hindgut?
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distal 1/3 of the transverse colon
descending colon sigmoid colon rectum |
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Sympathetic innervation of esophagus
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T2-8
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Sympathetic innervation of upper GI tract
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T5-9
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Sympathetic innervation of middle GI tract
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T10-11
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Sympathetic innervation of lower GI tract
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T12-L2
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Which nerve synpases at the celiac ganglion?
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greater splanchnic (T5-9)
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Which nerve synpases at the superior mesenteric ganglion?
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lesser splanchnic (T10-11)
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Which nerve synpases at the inferior mesenteric ganglion?
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least splanchnic (T12-L2)
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Sympathetic innervation of the Lower GI tract.
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T12-L2
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Path of sympathetic innervation (spinal cord to organ)
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dorsal horn --> sympathetic chain --> splanchnic nerve --> ganglion --> Target organ
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Effects of sympathetic innervation of the foregut
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vasoconstriction and alteration of bicarbonate and mucus buffers
decreased mucosal defenses against digestive acids and enzymes inflammation (gastritis) and ulceration (PUD) Decreased lower esophageal sphincter tone--> Reflux |
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Effects of sympathetic innervation of the midgut
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vasoconstriction, decreased peristalsis
- ileus - constipation - distention - flatulence - abdominal pain |
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Effects of sympathetic innervation of the hindgut
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vasoconstriction, decreased peristalsis
- Ileus - constipation - flatulence - abdominal pain Relaxation of sphincters |
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Chapman's reflex of Liver
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Right 5th and 6th ICS
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Chapman's reflex of Stomach Acid
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Left 5th ICS
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Chapman's reflex of Gall bladder
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Right 6th ICS
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Chapman's reflex of Stomach peristalsis
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Left 6th ICS
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Chapman's reflex of Pancreas
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Right 7th ICS
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Chapman's reflex of Spleen
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Left 7th ICS
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Parasympathetic innervation of the Upper GI tract
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Vagus nerve
Left vagus = greater curvature and pyloric sphincter of the stomach Right vagus = lesser curvature, liver, gall bladder, right half of colon |
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Parasympathetic innervation of the lower GI tract
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Pelvic Splanchnic Nerves (S2-4)
left colon and pelvis |
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Effects of Parasympathetic innervation on the GI tract
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increased secretion rate of most GI glands (acid, amylase, lipase, etc.)
increased peristalsis--> diarrhea Contraction of gallbladder and ducts (secretion) Increased Sphincter tone |
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How much does lymphatic return increase in times of stress?
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4-5 times normal
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How much does lymphatic return increase in chronic dysfunction?
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40 times normal
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To which lymphatic organ do organ systems below the diaphragm drain?
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they drain into the cisterna chyli and then into the thoracic duct
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Where is the cisterna chyli located?
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adjacent to the aorta at the right crus of the diaphragm
at the level of L1-2 |
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What are the effects of impaired lymph flow?
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Increased tissue congestion
Impaired nutrient absorption Increased risk of pancreatic complications in gallbladder disease/dysfunction |
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Sympathetic reflex of the esophagus
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T3 right
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Sympathetic reflex of the stomach
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T5-8 left
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Sympathetic reflex of the duodenum
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T7-8 right
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Parasympathetic reflex from the stomach
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high cervical vagal reflex (C2)
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Upper GI reflex
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C2 left
T3 right T5 left T7 right |
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Sympathetic reflex of the small intestine
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T8-10 bilateral
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Sympathetic reflex of the appendix
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T12 right
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Sympathetic reflex of the descending colon
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L2-3 left
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Chapman point of the appendix
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tip of the right 12th rib
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Sympathetic dominant complaints
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constipation
abdominal pain flatulence distention |
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Parasympathetic dominant complaints
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Headache
nausea vomiting diarrhea cramps or pain from the GI tract |
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Lymphatic congestion complaints
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all disease of the colon
fatigue constipation diarrhea pain and cramps |
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Timeline of symptoms for pancreatitis
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1. Initial VS findings from T5-9
2. Flattening of thoracic kyphosis 3. Parasympathetic reflex from OA to C2 4. Associated etiologies = GB reflex, alcoholic hepatitis 5. Development of ileus 6. Nausea and Vomiting - Vagal reflex OA - C2 - Esophagus from T2-T8 - Stomach from T5-9 |
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Number one and number two causes of pancreatitis
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1. alcoholism
2. gallstones |
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Hemorragic pancreas leads to which life threatening condition?
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ARDS = Adult Respiratory Distress Syndrome
leads to fibrodic changes in lungs |
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Expected lab results for chronic pancreatitis
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increased serum amylase
increased serum lipase leukocytosis hyperglycemia calcification in the pancreas on x-ray |
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Signs and symptoms of pancreatitis
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epigastric abdominal pain--may radiate straight through to the back
nausea and vomiting low-grade fever mild jaundice diminished or absent bowl sounds Grey Turner's sign Cullen's sign Pleural Effusion Hypotension/Shock |
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Grey-Turner's sign
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discoloration caused by massive nontraumatic ecchymoses in the skin of the lower abdomen and flanks. It results from the infliltration of the extraperitoneal tissue with blood
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Cullen's sign
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faintly blue coloration as a result of retroperitoneal bleeding
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Does biliary tract disease (cholelithiasis and choledocholithiasis) cause chronic pancreatitis?
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No, it can cause recurrent acute attacks but not chronic
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Does alcoholism cause chronic pancreatitis?
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yes, it also causes acute pancreatitis
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Treatment for pancreatitis
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85-90% is self-limited
analgesics IV Fluids No oral alimentation (rest the pancreas) nasogastric suction = decrease the gastrin in stomach and prevent gastric contents in the duodenum OMT |
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Ranson's criteria
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On admission:
- Age over 55 years - WBC > 16,000 - Serum LDH > 350 - Blood glucose > 200 - SGOT (AST) > 250 In Initial 48 hours: - Hemocrit decreased > 10% - BUN increase > 5 - Ca++ < 8 - Arterial pO2 < 60 - Base deficit > 4 - Fluid sequestered > 6L |
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Vicerosomatic reflex of pancreatitis
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T7 on Right or bilateral
**tends to be non-neutral |
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How can ischemia affect pancreatits?
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it can change non-lethal pancreatitis to lethal pancreatitis
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Where would you see tenderness that indicates hypersympathetonia of one or more organs innervated by the greater splanchnic and celiac ganglion (T5-9)
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tenderness just inferior to the xyphoid process
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Anterior Chapman's reflex of the pancreas
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lateral to costal cartilage between 7th and 8th ribs on right
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Posterior Chapman's reflex of the pancreas
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between transverse processes of T7-8 on the right
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In which patients would you avoid NSAIDs?
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stomach problems (chapman's reflex at T3 posteriorly or 5th and 6th ICS on left anteriorly)
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In which patients would you avoid tylenol (acetominophen)?
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Liver problems (5th and 6th ICS on the right anteriorly)
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Secretion evoked by secritin and CCK depends on what?
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a permissive role of vagal afferent
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Parasympathetic innervation effects when stimulated
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increases pancreatic juices rich in enzymes
stimulates the production of bile may cause a headache because of interchange with somatic innervation in neck |
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Are there lymphatics in the endocrine pancreas?
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No, none in the islets
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Path of lymphatics in the pancreas
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follow the blood vessels to the pancreaticosplenic nodes --> celiac nodes -->--> left thoracic duct
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When the abdomen muscles are weak, which muscle takes over to provide stability to the trunk? In which condition is this normally seen?
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Psoas --> can cause it to be spastic and to lower it's threshold for firing
Seen in pancreatitis |
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OMT Treatment plan for pancreatitis
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Facilitated segments (sympathetics) --> work on chapman points
Treat psoas muscle Lympatics --> pancreaticosplenic nodes to celiac nodes; thoracic inlets (abdominal diaphragm) Treat thoracolumbar junction (diaphragm attachments) Treat parasympathetics --> OA |
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Increased tone of sympathetics in T5-9
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increased mucosal sensitivity to H+ concentration and alters mucosal barrier
vasoconstriction decreased peristalsis which leads to constipation relaxation of gallbladder and ducts (no secretion) |
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Increased parasympathetic tone to the GI tract
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increased acid secretion
increased peristalsis which can cause diarrhea contraction of gallbladder and ducts (secretion) |
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GI complaints of increased parasympathetics
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hypermotility related cramping/pain
diarrhea nausea and vomiting |
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OMT for PUD
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Rib raising (T5-9 and T10-11)
Chapman's Reflexes Collateral (celiac ganglion) Work on Thoracic inlets: - Abdominal diaphragm via cervical C3-5 (phrenic nerve) - Thoracolumbar junction (diaphragm attachment) Parasympathetics = Vagus nerve (OA, AA, C2, Cranial Sacrum) |
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describe the location of epigastric pain
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sub-xiphoid
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Which diagnostic test would be elevated with a rapid GI bleed?
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BUN
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Which GI disorder could be a possible cause for asthma attacks or night time coughing?
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GERD or acid reflux
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OMT for GERD
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Rib raising (T5-9)
Chapman's reflexes and collateral ganglion Thoracic inlets = abdominal and diaphragm Parasympathetics = SI joint, OA, OM suture |
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Four F's of gallbladder dysfunction
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Forty
Female Fat Flatulance |
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Rovsing sign
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when you push on the left side of the abdomen and the right side elevates; tests for apendicitis
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Sympathetic innervation of the bile duct
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T6 on the right
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Sympathetic innervation of the gallbladder
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T5 on the right
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Lymphatic pathway from the gallbladder
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gallbladder --> retroportal node --> abdominoaortic nodes --> thoracic duct
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Anterior Chapman's reflex of the gallbladder
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6th and 7th ICS on the right near the costochondral junction
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Typical signs and symptoms of IBS
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affect patients under 40, but not over 50
women 2-3x more often than men diarrhea and/or constipation absence of detectable structural abnormalities mild neurotic personalities, people under stress, rigid thinkers, orderly, conscientious preceding psychiatric illness is common but may be masked by systemic complaints |
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NOT typical signs and symptoms of IBS
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weight loss
fever rectal ulcerations and rectal bleeding anemia increased likelihood of colon cancer |
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Functional characteristics of IBS
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Altered slow wave ratios hinders forward flow of fecal contents
delayed and prolonged reaction to stimuli decreased nerve threshold levels encouraging excessive reaction to stimuli that would otherwise be normal intense emotional reactions = sympathetic hypersensitivity abnormal contraction patterns of the intestines excessive gas abdominal pain |
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chapman's reflexes of the colon
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Right:
Iliocecal area (hip) ascending colon hepatic flexure right 2/5ths of transverse colon (knee) Left: sigmoid area (hip) descending colon left 3/5ths of transverse colon (knee) |
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Pharmalogic treatment for IBS
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antispasmotics
antidiarrheals TCA's Antacids/H2 inhibitors |
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Dietary treatment for IBS
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gradual addition of bulk forming agents and fiber
lactose and fat restriction water |
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OMT for IBS
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Rib raising = T5-L2
Chapman's reflexes Work on psoas and piriformis muscles Lymphatics = pelvic diaphragm, spleen, and presacral fascia Parasympathetics = sacrum |
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Components that cause post-op ileus (somatovisceral and viscerosomatic components)
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somatovisceral = neurogenic impulses resulting from the incision of the soma
viscerosomatic = result of bowel handling during surgery **Results in increased sympathetic tone and decreased mobility |
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OMT for Post-op ileus
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inhibition of hypertonic PVM, rib raising, lumbar inhibition
Correction of facilitated vertebral segments Indirect MFR of the T-inlet, diaphragm, mesenteries, and lymphatic pumps as tolerated |
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Somatic dysfunction seen in ileus
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generally rotational component of S/D will be toward side of visceral dysfunction especially if organ is paired
HVLA often unsuccessful especially if palpation of paraspinals demonstrates rubbery texture |
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Does HVLA work on the facilitated segments of a vicerosomatic reflex?
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No
Plus, you should avoid HVLA in most hospitalized post-surgical patients |
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Describe the pain seen in appendicitis (true visceral and viscerosomatic pain)
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true visceral pain = initially referred pain and cramping is sensed in the periumbical region
viscerosomatic pain = chapman reflex point at the tip of the 12th rib on the right Percutaneous Reflex of Morely Phrenic Pain |
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Percutaneous reflex of Morley
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if appendix touches the anterior peritoneum, the localized RLQ becomes more symptomatic
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Other signs seen with appendicitis
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McBurney's point
Rovsing's sign Rebound tenderness Psoas Sign Obturator Sign |
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What may you see in the UA that could lead you to think of appendicitis?
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RBCs = if the appendix is pushing on the ureter, it may cause it to become inflamed which increases permeability
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Retrocecal appendix
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irritation and spasm of the psoas
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Iliopsoas test
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patient lies on the left side and extends the right leg at the hip against the resistance of the examiners hand
a positve psoas sign = abdominal pain with this maneuver irritation of the right psoas muscle by an acutely inflamed appendix produces a right psoas sign |
