Using Osteopathy in the Diagnosis of Peptic Ulcer Disease
A case study in formulating the diagnosis of Peptic Ulcer Disease.
By Emily Colyer, OMS III
ABSTRACT: This case study illustrates the role of an osteopathic physician in both diagnosing and treating peptic ulcer disease. An osteopathic perspective was utilized while obtaining the patient history and in formulating the diagnosis of peptic ulcer disease. In the course of treatment, this case study demonstrates the effective implementation of an osteopathic approach combined with conventional medicine.
Peptic ulcer disease is marked by the formation of erosion and ulcerations in the gastric mucosa of the stomach or duodenum. Duodenal ulcers are associated antral predominant gastritis, where as the gastric ulcer is associated with pan-gastritis, with below normal acid secretion.
Etiological factors that are presented as causative agents in the formation of peptic ulcer disease are: caffeine, smoking, stress, NSAIDS, gastronomias and helicobacter pylori infection. There is also an increased frequency of ulcers in persons with the blood group O.1
In the normal gastrointestinal tract the body is equipped with defense mechanisms that prevent the formation of ulcers. These include: adequate blood flow, production of mucus, bicarbonate, and prostaglandins, and epithelial renewal. If an imbalance occurs in the factors that insult and protect the gastric lining, then there is potential for the formation of ulcers.
Patients with peptic ulcer disease may present with symptoms of epigastric pain, dyspepsia, and belching. They also may note bloating and abdominal distension. If a patient has an ulcer that progresses to a bleeding ulcer, the presence of melena, or dark colored stools, may be noted.
The epigastric pain noted by the patient may be either relived or aggravated by food, depending on whether the ulcer lies in the duodenum or in the stomach. Other signs that may sometimes be overlooked by physicians are somatic manifestations of visceral disease. This would include tissue texture changes or asymmetry in the patient’s thoracic region.2
Peptic ulcer formation has been linked to the digestive function of the gastric acid pepsin. Also, disruption of the nutritive process in the body may predispose the surrounding tissues to disease. This may be the case if the gastric mucosa has decreased lymphatic or venous drainage, decreased blood flow, increased acid production, or decreased glandular secretions.
Patients sometimes present with upper back and neck pain or pain adjacent to the shoulder blades and they assume that they have muscle tightness or strain from work, lifting weights, stress, or muscle tension. Osteopathic physicians are trained to look beyond the patient’s presenting complaints to elucidate the cause of the symptom.
Both the sympathetic and parasympathetic nervous systems send nerve fibers throughout the body, innervating muscle, skin, glands, and visceral organs. Increased drive to either of the autonomic nervous system branches that disrupts the normal balance of the body, can cause organ dysfunction.
Dr. Andrew Taylor Still said, “If the nerve and blood supply and the proper functioning of each organ of the abdomen is dependant on the solar plexus, then we have a dyspeptic for diagnosis and treatment, we will go up to the origin of the great splanchnics in the spinal chord. Explore the spine in the region of the branching segments of the splancic nerves. If you find the, fifth, sixth, seventh, or eighth ribs of the right side in mal-position, then you know that you are on the right track and have a diseased solar plexus.”3
Case Report: Patient L.G.
A 36-year-old female presented to the office with a complaint of neck pain, thoracic pain, bilateral epicondylitis, and pain in her left shoulder and left hand. She said that her pain was rated at about a 6/10. The most recent episode she could recall began in 2006, but the patient stated that she had been experiencing similar symptoms since 1997. She expressed that she had tried rest, heat, ice, and some pain medications, which had offered only temporary relief.
Repetition of activity and driving often aggravated the pain. She had some weakness, along with some tingling in the left hand. Somewhat disturbing to the patient was that her pain often interfered with her ability to go to sleep and would awaken her from sleep at night.
She had tried Zolpidem to help her sleep, Hydrocodone for the pain, and metaxalone as a muscle relaxant. She was not currently on any daily medications, except: a progestin/estrogen contraceptive.
The patient’s history of surgeries and incidents of trauma, included three normal vaginal deliveries between 1989 and 1999, a fracture of the right great toe as a child and a rear impact motor vehicle accident in 2005.
The patient worked as a computer data entry clerk. She denied any history of smoking and drank alcohol socially. She had no known drug allergies and denied seasonal allergies. The patient’s family history included obesity, diabetes mellitus type 2, elevated cholesterol, and coronary artery disease for her father, and hypothyroidism for her mother.
The patient was examined in the walking, standing, sitting, supine, and prone positions. Her gait was normal, with no limp noted. On profile there was anterior head carriage and flattening of the dorsal kyphosis, between T3 and T7. There was no short leg noted, and there was a positive flexion test, both standing and seated on the left side. With the patient supine, the left innominate was found to be rotated anteriorly, which was treated with muscle energy.
The patient was then examined in the prone position. The bony elements of the pelvis were assessed and no sacral somatic dysfunctions were noted. The lumbar spine had a neutral group restriction from L1-L5, restricted rotation left, side bending right that mobilized easily with a lateral recumbent high velocity low amplitude, HVLA, procedure.
There was restriction of the lower ribs bilaterally, which was worse on the left, with ribs seven to 10 held in a position of relative inhalation. The ribs were easily mobilized with prone HVLA procedure. The segments above from T1-T3 were restricted in rotation to the right and side bending to the left, which were treated with prone HVLA.
There was non-neutral somatic dysfunction present at T6, restricted rotation and side bending to the left. Since this is the reference zone for the gastrointestinal system, the patient was questioned about heartburn and belching, to which she responded in the affirmative. When questioned about headaches, the patient admitted to having right sided headaches that start at the right suboccipial region, radiating to the right retro orbital location.
On abdominal examination, the belly was soft, non-obese, and there was reproducible tenderness in the mid-eppigastric region over the duodenal cap.
The cervical spine was examined with the patient in the supine position and the subocciput was restricted in side bending right and rotation to the left at the OA joint. These findings supported the differential diagnosis of gastrointestinal insult. Active mobilization of the OA joint was easily preformed with HVLA.
Upon further inquiry of the patient, she admitted to not being a breakfast eater. She also had experienced night wakening between the hours of 3:00 a.m. to 4:30 a.m., almost nightly. Additional questioning revealed a family history of hyperacidity. Due to supportive evidence from both the physical exam and patient history, a prescription for Nizatidine 150 mg was offered to the patient to be taken with meals. She was strongly encouraged to develop a habit of eating a protein rich breakfast within an hour of awakening.
Following treatment the patient was asked to stand again. She had weakness of grip strength bilaterally as well as increased carrying angle bilaterally. With the patient supine, active mobilization of both abducted ulnas was successful and there was less than 50 percent improvement in grip strength bilaterally.
Upon final assessment of the patient her diagnoses included: gastritis duodenitis with possible peptic ulcer disease; bilateral epicondylitis; somatic dysfunction of the cervical, thoracic, lumbar spine, pelvis, and upper extremities. Treatment modalities that were chosen for the patient included Osteopathic manipulative medicine, which was preformed in the clinic, and a prescription for an H-2 blocker with meals was written. She was instructed to avoid the use of non-steroidal anti-inflammatory medications, and dietary changes were encouraged, including the consumption a protein rich breakfast daily, and she was advised to avoid propping up on her elbows at work. A follow up appointment was scheduled for three weeks.
Ten days from the start of treatment the patient was contacted to inquire about her progress. The patient stated that her neck and upper back pain was greatly relieved; with a pain level of three on a scale of one to 10. She reported having no headaches since her appointment and was sleeping better throughout the night. The patient commented that the nizatidine also had helped tremendously and she was no longer experiencing belching or heartburn.
Literature Review:
Korr4 states that chronic sympathetic hyperactivity is often a critical factor in clinical syndromes such as peptic ulcer disease. The sympathetic nerves that supply the upper portion of the gastrointestinal system are T5-T9 via the greater splanchnic nerve.
Increased stimulation of the sympathetic nervous system leads to increased mucosal sensitivity to hydrogen ion concentration, increases vasoconstriction, and decreases motility of the gastrointestinal tract. The parasympathetic innervation supplying the gastrointestinal tract is the vagus nerve. Increased tone of the parasympathetic nervous system leads to increased acid secretion, increased motility, and decreases glandular secretions of mucous.
Due to the shared innervations of the autonomic nervous system, there is the formation of visceral somatic reflexes. Visceral somatic reflexes come from the visceral tissue and then are transmitted by afferent impulses to the dorsal horn of the spinal cord where they synapse with the interconnecting neurons. The spinal efferents send stimuli to the parasympathetic and motor system that cause regulatory changes to occur in the muscles, blood vessels, and skin.4
The somatic manifestations of visceral disease are viewed by many to be an integral part of the disease process, not just a sign of illness. These abnormal reflexes become chronic and self-sustaining and often impair healing and recovery.4
The sustained facilitation of the sympathetic nervous system and its clinical impact are determined by the segmental level of the affected outflow. Korr also discussed the spinal cord as an organizer of not only normal adaptive behavior but also as an organizer of disease processes.5
Lousia Burns found that when animals were artificially lesioned at the fifth thoracic segment, they would show erosions and ulcerations of the gastric mucosa and hyperchlorhydria. Many correlations have been made to lesions the third through sixth thoracic vertebra as factors in the development of peptic ulcer disease.6
Others have noted that thoracic somatic dysfunction many hinder the healing of peptic ulcer disease. Meyers7 reported a case of long standing peptic ulcer disease that was markedly helped by correction of a fifth thoracic lesion and marked spasticity of the neck.
Relief of the fascial changes and soft tissue contractions may help to promote healing of the visceral dysfunction; in this case, it might prove to promote the healing of the disrupted gastrointestinal functionality. The healing process of peptic ulcer disease and gastritis can be aided with the use of osteopathic manipulation to the thoracic region of the spine.
Restoring equilibrium to the autonomic nervous system facilitates improved gastrointestinal, lymphatic and venous drainage. In turn, mucous and gastric acid secretion are exchanged and restoration of proper notility can be achieved.
The tissue effected by gastritis and peptic ulcer disease often becomes rigid and endematous, as well as the tissue that surrounds the solar plexus. These tissues should be treated gently with osteopathic manipulation in order to make sure that drainage is unobstructed.8 Webster9 called the region just below the diaphragm the “death belt,” convinced that imperfect lymphatic or venous drainage produces pathological states in the stomach, duodenum, liver, gallbladder, spleen, and solar plexus.
This osteopathic paradigm illustrates the importance of being cognizant of the somatic triad?of the skin, dorsal musculature, and verterabral articulation?as the etiological factor in many cases of visceral disease.10
Osteopathic Treatment options for decreasing hypersympathetic tone include:
Osteopathic treatment options for Regulating the Parasympathetic Nervous System include:
Discussion
Traditional diagnosis and treatment of ulcerative gastritis has depended on the pathology present in the patient. Once the patient’s disease is advanced to the point of severe symptoms, often the patient goes under a thorough evaluation including an upper GI series or EGD to determine if gastritis or ulceration is present.
One of the distinguishing characteristics of osteopathy is the use of structural diagnosis and manipulative treatment, along with other conventional forms of medicine in order to diagnosis and effectively care for patients. If the physician gives consideration to physical findings to aid with the diagnosis of peptic ulcer disease, then the patient can be started on trial therapy for peptic ulcer disease and gastritis, and possibly avoiding an expensive workup that would result in a similar outcome. The presence of contractions of the muscles of the mid-thoracic region of the spine should be a signal to the physician to look for visceral causes of dysfunction.
It has been observed that if the tenderness or pain in the area of dysfunction is out of proportion for the area of insult, then an underlying visceral cause of somatic manifestations likely exists. In a conversation with Jerry Dickey, DO (2007), he states that, the body does not know how to lie, and if he finds a tender area in the upper thoracic region, it heightens his suspension leading him to start looking deeper in the exam, so as not to miss what might be a manifestation of visceral disease.
As with all patients, the treatment should fit the patient, their health status, and toleration of treatment. While osteopathic manipulation may facilitate the recovery of the patient and decrease recovery time, many patients with peptic ulcer disease benefit from dietary changes, H2 blockers and proton pump inhibitors, or combination therapy.
Summary
Well rounded treatment for peptic ulcer disease would include: H-2 receptor antagonists and Proton pump inhibitors, treatment for Helicobacter Pylori if appropriate, dietary changes, and osteopathic manipulation where indicated. Dietary changes would include starting the day with breakfast consisting of a complex animal protein, followed by multiple protein rich meals each day. Osteopathic manipulation would be applied to areas of somatic dysfunction that overlap with areas that affect the gastrointestinal tract.
Emily Colyer, OMSIII attends the University of North Texas Health Science Center at Fort Worth, Texas College of Osteopathic Medicine.
References