this presentation explains anatomical and physiological basis for visceral osteopathic techniques

1. Visceral Osteopathy
Hossein Khorrami, Ph.D. DOMP

2. Cavities

3. Diaphragm
• Dome-shaped muscle with central tendinous
portion(phrenic center)
• 2-4mm thick
• Right crus (pedicle) insert onto L2-L3(L4)- body
and disc
• Left crus insert onto L2-L3- body and disc

5. Diaphragm, costal portion
• Insert into lower 6 ribs
• Crossing QL muscle and attach to TVP of L1
(lateral lumbocostal arch)
• Sternal portion attach to xiphoid process

7. Diaphragm, arcuate ligaments
• Medial, aorta
• Median, psoas muscle
• Lateral, quadratus lumbarum
• All are fibrous and non muscular
• But Esophageal hiatus(T10) contracts during
inhalation, so prevents reflux

8. Lower Esophageal Sphincter(LES)
• Epiphrenic ampulla
– Dilate with inhalation(compliance)
• Area of sphincter
– Diaphragmatic(hiatal anulus)
– Lower esophegeal

10. Esophageal motor innervation by the vagus nerve; Auerbach’s and
Meissner’s plexuses. The striated muscle of the proximal esophagus
is directly innervated by the somatic efferent cholinergic fibers of the
Vagus nerve originating from the nucleus ambiguous
In contrast, the smooth muscle of the distal esophagus is innervated
by the preganglionic vagus nerve fibers from the dorsal motor
nucleus. The preganglionic vagus fibers release Ach, that affects two
types of postganglionic neurons in the myenteric plexus, the
excitatory cholinergic neurons and the inhibitory nitrinergic neurons

11. Esophagogastric Junction
• Diaphragmatic sphincter
• Lower Esophageal Sphincter Complex
– LES
– Cardiac opening

12. Lower Esophageal Sphincter
• LES involves the distal 3-4cm of the esophagus
and at rest is tonically contracted
• Resting LES pressure: 10-30mmHg
• LES maintain a high-pressure zone by the
intrinsic tone of its muscle and by cholinergic
excitatory neurons
• Lowest pressure after meal & highest at night
• Also influenced by circulating hormones,
peptides, foods(esp fats) and drugs

13. LES Contracts
• In response to:
• Gastrin
• CCK
• Secretin
• Glucagon
• Acid

14. Pressures
• Intra-esophageal: -5cmH2O
• Gastric: 8cmH2O and more(27)
• LES: 14-55cmH2O
– Variable, related to the gastric pressure
– initial pressure <14 reflux
• Pressure inversion point at LES-Diaphragm
• Importance of air pocket in fundus area,
pushes esophagus up and stomach down

15. During inhalation
• Decrease esophageal pressure
• Increase abdominal pressure
GERD: GastroEsophageal Reflux Disease

17. Reflux
• Pyrosis(heartburn): burning sensation from
xiphoid toward sternum, rarely radiate to neck
and/or between shoulder blades
• Regurgitation: bitter and burning acidic liquid
to mouth without vomiting

18. Reflux, other signs
• Tracheobronchial irritation, esp nocturnal
• Asthmatiform crisis
• Pharyngeal pain
• Hiccup
• Otalgia(ear pain)
• Burping(Eructations)

19. The Vestibule
• The esophageal segment between diaphragm
and cardia
• Passes into abdomen
During inhalation and into
the thorax during
exhalation

21. Cardiac Orifice
• Opening of esophagus to stomach
• 2cm left of the midline
• At T11
• Ventral and left to aorta
• Connect with left lobe of liver, makes a groove
• Corresponds to the left 7th costal cartilage

22. Phrenicoesophageal ligament

23. Achalasia
• Results from a malfunction of the nerves
controlling the rhythmic contractions of the
esophagus
• Viral and autoimmune or..
• Certain tumors

24. Hiatal Hernia
• A hiatal hernia occurs when the
upper part of stomach bulges
through diaphragm

25. Hiatal Hernia, Symptoms
• Heartburn
• Regurgitation of food or liquids into the mouth
• Acid reflux
• Difficulty swallowing
• Chest or abdominal pain
• Shortness of breath
• Vomiting of blood or passing of black stools,
which may indicate gastrointestinal bleeding

26. Hiatal Hernia, Causes
• Age-related changes in diaphragm
• Injury to the area, for example, after trauma
or certain types of surgery
• Being born with an unusually large hiatus
• Persistent and intense pressure on the
surrounding muscles, such as vomiting,
coughing, straining during a bowel movement,
exercising or lifting heavy objects

27. Mesenteries In Saggital Plane

39. Gastric Hcl Secretion
Gastric HCl Secretion
Proton Pump
(H,K-ATPase)
Na+ Pump
(Na,K-ATPase)
ATP
Na+
K+
HCl
Lumen of
gastric gland
Fig. 21-6

48. Pancreatic juice

49. Endopeptidases
• Pepsin (stomach), cleaves at amino side of
aromatic A.A.'s
• Trypsin (pancreas), cleaves at COOH side of basic
A.A.'s, i.e., lys & arg
• Chymotrypsin (pancreas), cleaves at COOH side of
aromatic A.A.'s, also leu and met
• Enteropeptidase (duodenum) cleaves at COOH
side of Lys that is preceded by 4 Asp and followed
by non-Pro

50. Exopeptidases
• Carboxypeptidase (pancreas), C-terminal peptidase
• Aminopeptidase (intestine), N-terminal peptidase

51. Digestive enzymes

53. (from duodenal epithelial
cells)
CCK
works on
acinar cells
#-Amylase
Lipase
(no activation needed)
b. Secretion/Activation of Pancreatic Enzymes
secreted by duodenal
epithelium
(Enterokinase)
(cholecystokinin)

55. Surface anatomy of abdomen

56. Duodenum

60. Liver Functions
• Filter: bacteria, antigens, damaged cells, proteins, hormones and
drugs
• Detoxification: ammonia, alcohol., etc
– alcohol to acetaldehyde(carcinogen)
• Blood reservoir
• Nutrient processor
• Protein synthesis: albumin, binding proteins, transferrin, globulins,
blood clotting factors, fibrinogen, prothrombin, v, vii, ix, x.., apolipoproteins,
angiotensinogen
• Glucose, lipid homeostasis, gluconeogenesis,
• Minerals, Iron & vitamin storage
• Bile synthesis by destruction of old Rbcs

61. Hepatic Ligaments
• R triangular
• L triangular
• Falciform
• Round,
– remnant of L umbilical vein
• Hepatogastric
• Coronary(to diaphragm)

67. Liver Referred Pain

68. Intestines
• Small: 7meters
• Large: 1.5 meters

72. The Large Intestine
The Large Intestine

86. Spleen, Position

90. Referral pain

92. Liver, ligaments
• Round ligament (ligamentum teres)
• Coronary ligament
• Right triangular ligament
• Left triangular ligament

93. Liver ligaments

94. Liver, treatment, side
• Push the liver on both sides With Every Breath
• Push the liver WEB, finish with vibration
• Do the same, finish with rebound
• Stretching on R side, using one elbow on
pelvic, the other below arm + move back &
forth + stretching
• Do the same with leg stretch
• Do the same with hand stretch

95. Gallbladder, treatment, sitting
• Midclavicular line, below rib8
• Push post+sup

98. Stomach, attachments
• Liver
• Transvers colon
• Descending colon

100. Sympathetic nerve
• Greater splanchnic and Lesser splanchnic
nerves join to celiac ganglion
• Between crura of diaphragm and expansion of
psoas arch

102. Pneumogastric (Vagus ) nerve
• 10th cranial nerve, from medulla
• Passes through jugular foramen, at middle
part of temporal-occipital suture

103. Vagus, functions
• Sensory
– Skin of posterior auricular area + part of external
auditory meatus
• Motor
– With 9th & 11th cranial nerve innervate palatal &
pharyngeal muscles, in deglutition
– Innervate larynx, role in phonation
• Vegetative
– Taste from base of tongue
– Proprioception of larynx & pharynx, protective role for
airways
– Carotid baroreceptors

104. Vagus, pneumogastric portion
• A visceral nerve
• Extending to thoracic and abdominal viscera
• Proprioception of lungs, GI tract, heart and
great vessels (carotid sinus)
• Controls SM of lungs, esophagus, intestine
• Stimulate bile and gastric secretions

106. Vagal system

107. Second Brain
• We know the basic steps to keeping a young,
healthy brain: eat healthy, exercise, and get a good
night’s sleep
• Our brain health may also be influenced by an
unexpected source, our second brain
• Within the walls of our digestive system, the gut, or
the “second brain,” which contains bacteria that
could help our brain structure, possibly influencing
our moods, behavior, and mental health, such as
the likelihood of developing Alzheimer’s disease

108. • The gut is able to communicate with the brain
via the vagus nerve, a cranial nerve extending
from the brainstem to the abdomen via the
heart, esophagus and lung, known as the gut-
brain axis
• Ninety percent of the fibers in the vagus carry
information from the gut to the brain

110. Colon: net absorption of salt and water, but also some secretion of K+
(Colon participates with kidneys in regulating body K+.)
HH22OO
NaNa++
ClCl--

111. NaCl Secretion by the Colon
(minor, except when pathological)

114. Colonic bacteria
There is very little nutrient absorption by the colon,
however:
Short-chain fatty acids produced by colonic bacteria:
1) taken directly across apical membrane of colonocytes
2) many used by colonocytes as preferred metabolic substrate
Vitamin K and biotin: absorbed in small intestine from dietary
sources, but also produced by colonic bacteria and absorbed
across colonic epithelium

116. Crohn’s Disease
• inflammatory bowel disease (IBD)
• 3-3.5/1000
• It causes inflammation of the lining of digestive tract
– Abdominal pain
– Severe diarrhea
– Fatigue
– Weight loss
– Malnutrition
• Inflammation caused by Crohn's disease can involve
different areas of the digestive tract from mouth to the
rectum in different people

118. • The inflammation caused by Crohn's disease
often spreads deep into the layers of affected
bowel tissue
• Crohn's disease can be both painful and
debilitating, and sometimes may lead to life-
threatening complications
• In some people with Crohn's disease, only
ileum is affected
• In others, the disease is confined to the colon

119. Symptoms
• Diarrhea is a common problem
• Fever and fatigue due to inflammation or infection
• Abdominal pain and cramping
• Nausea and vomiting
• Night sweats
• Blood in stool, visible or occult blood
• Mouth sores
• Reduced appetite and weight loss
• Perianal disease (fissures and fistula)
• Inflammation of skin, eyes and joints
• Inflammation of the liver or bile ducts
• Delayed growth or sexual development, in children

120. • Immune system. It's possible that a virus or
bacterium may trigger Crohn's disease
– Mycobacterium
– Listeria
– …
• Heredity. Crohn's is more common in people who
have family members with the disease, so genes
may play a role in making people more
susceptible. However, most people with Crohn's
disease don't have a family history of the disease

121. • Age. Crohn's disease can occur at any age, but most people who
develop Crohn's disease are diagnosed before they're 30 years old
• Ethnicity. Although Crohn's disease can affect any ethnic group,
whites and people of Eastern European (Ashkenazi) Jewish descent
have the highest risk
• Family history. As many as 1 in 5 people with Crohn's disease has a
family member with the disease
• Cigarette smoking is the most important controllable risk factor
• NSAIDS, ibuprofen (Advil, Motrin IB, others), naproxen sodium
(Aleve, Anaprox), diclofenac sodium (Voltaren, Solaraze). While they
do not cause Crohn's disease, they can lead to inflammation of the
bowel that makes Crohn's disease worse
• Live in an urban area or in an industrialized country. This suggests
that environmental factors, including a diet high in fat or refined
foods, play a role in Crohn's disease. People living in northern
climates also seem to be at greater risk

122. Crohn’s disease
• file://localhost/Users/Home/Downloads/Croh
n_disease_video.webm.480p.ogv

124. Coeliac disease
• Autoimmune disease, not a food allergy
• Affects small intestine
• Any age
• Reaction of gut to gluten
• Gluten in wheat, barley and rye
• Intestinal villi become flattened as a result of
the inflammation
• Food and nutrients are not so
readily digested by the body

125. Symptoms
• Abdominal pains, tiredness and weight loss
• In babies starting solid foods,
– pale stool, smelly diarrhea
– Vomit repeatedly
– Fail to grow or poor growth
– In adults
• Weight loss
• Anemia because of poor iron absorption
• Diarrhea, abdominal bloat
• Mouth ulcer

126. Sugar hurts liver
• The organ uses one type of sugar, called fructose,
to make fat
• Too much refined sugar and high-fructose corn
syrup causes a fatty buildup that can lead to liver
disease
• Some studies show that sugar can be as
damaging to the liver as alcohol, even if you’re
not overweight
• It’s one more reason to limit foods with added
sugars, such as soda, pastries, and candy

127. Herbal supplements
• Even if the label says “natural,” it may not be
OK for you. For instance, some people take an
herb called kava kava for menopause
symptoms or to help them relax
• Studies show that it can keep the liver from
working right
• That can lead to hepatitis and liver failure
• Some countries have banned or restricted the
herb, but it’s still available in the U.S.

128. Over weight
• The extra fat can build up in your liver cells
and lead to non-alcoholic fatty liver disease
(NAFLD)
• As a result, your liver may swell
• Over time, it can harden and scar liver tissue
(cirrhosis)
• You are more likely to get NAFLD if you are
overweight or obese, middle-aged, or have
diabetes

129. Vitamin A
• Your body needs vitamin A, and it’s fine to get
it from plants such as fresh fruits and
vegetables, especially those that are red,
orange, and yellow
• But if you take supplements that have high
doses of vitamin A, that can be a problem for
your liver

130. Soft drinks
• Research shows that people who drink a lot of
soft drinks are more likely to have non-
alcoholic fatty liver disease (NAFLD)

131. Acetaminophen
• Be sure to take the right amount! If you
accidentally take too much of anything that
has acetaminophen -- for instance, a pill for
your headache and something else for your
cold, and both have acetaminophen in it -- it
can harm your liver. Check the dose and how
much is OK to take in one day. Stick to those
limits, and you should be fine

132. Trans fats
• Trans fats are a man-made fat in some
packaged foods and baked goods
• A diet high in trans fats makes you more likely
to gain weight
• That’s not good for your liver. Check the
ingredients list
• Even if it says “0” grams of trans fat, it may still
have a small amount, and that adds up

133. Alcohol
• You probably already know that drinking too much is
bad for your liver
• But you might not realize that “too much” can happen
without you being an alcoholic or addicted to alcohol.
It’s easy to drink more than you think. Many glasses
can hold a lot more than one standard serving, which is
5 ounces of wine (that’s a little more than half a cup),
12 ounces of regular beer, or 1.5 ounces of liquor
• If you drink, be sure to keep it moderate -- that’s one
drink a day for women and up to 2 per day for men

134. Lymph nodes
• Lymphatic vessels lead into lymph nodes
• The body has around 600 to 700 of lymph
nodes in the groin, neck, armpits, around the
heart, lungs, and intestines
• The largest concentration of lymph tissue
called gut-associated lymphatic tissue (GALT)
surrounds the intestines

135. • Lymphatic fluid flows primarily upwards
towards the neck
• The lymphatic system has no pump of its own
and must rely on the movement of the body’s
musculoskeletal system to circulate

136. Ways to activate lymphatic system
• Movement/ Exercise
• Deep diaphragmatic breathing
• Rebounding
– Rebounding is the equivalent to jumping up and
down on a mini-trampoline
• Dry Skin Brushing or Effleurage

138. • Circular muscular fibers
• Gastrophrenic ligament
• Coronary falx of the stomach

140. Coronary falx of the stomach
• Peritoneal fold formed by gastric artery
• Concave below, stretched out between celiac
trunk and posterior flank of lesser curvature

142. Lungs, evaluation, supine
• Push on shoulder + Breathing
• Push scapula and anterior of ribs + breathing
• Push sides of sternum with knife hand +
breathing
• Push both hands on sternum + breathing
• Push diaphragm + breathing
• Hold trapezius muscle + push rib1

144. Description Vertebral
level
Contents
Caval opening T8 The caval opening passes through the central tendon of the
diaphragm. It contains the inferior vena cava and some
branches of the right phrenic nerve
Esophageal hiatus T10 The esophageal hiatus is situated in the posterior part of the
diaphragm, located slightly left of the central tendon
through the muscular sling of the right crus of the
diaphragm.
It contains the esophagus, and anterior and posterior vagal
trunks
Aortic hiatus T12 The aortic hiatus is in the posterior part of the diaphragm,
between the left and right crus.
It contains the aorta, the azygos vein, and the thoracic duct
two lesser apertures
of right crus
greater and lesser right splanchnic nerves
two lesser apertures
of left crus
greater and lesser left splanchnic nerves and the hemiazygos
vein

145. Description Vertebral
level
Contents
behind the diaphragm,
under the medial
lumbocostal arch
sympathetic trunk
areolar tissue between
the sternal and costal
parts (see also foramina
of Morgagni)
the superior epigastric branch of the internal thoracic
artery and some lymphatics from the abdominal wall
and convex surface of the liver
areolar tissue between
the fibers springing from
the medial and lateral
lumbocostal arches
This interval is less constant; when this interval exists,
the upper and back part of the kidney is separated
from the pleura by areolar tissue only

146. Goal of treatment
• Liberate all tension restraining the original
diaphragmatic dynamic imposed on the intra-
abdominal organs and to restore the plasticity
and elasticity of those organs in order to
maintain their homeostasis

147. Subjects
• Lungs and Diaphragm
• Liver
• Gallbladder
• Pancreas
• Stomach
• Intestine
• Kidney
• Bladder
• Uterus

148. Visceral Osteopathy
• Evaluation techniques
• Treatment techniques

149. Contraindications
• Bone fracture
• Tumor
• Infection
• Pregnancy
• Scar/bleeding

150. Treatment techniques
• Push
• Mobilization
• Vibration
• Recoil/Rebound (Lymphatic Technique)
• Scooping

151. Lungs, active evaluation, sitting
• Compare 2 sides
• Put both hands over shoulder girdle+ breathing
• Put hands around ribs below arm on each side
• Put hands on both sides + breathing
• Hands below diaphragm(from back)
• Hands over chest (upper ribs) from back
• Push rib 1 on both sides
• Push hands over sternum and thoracic vertebra

152. Lungs, passive evaluation, sitting
• Similar to active, but try to move chest from
different areas
• Push cartilaginous parts of chest