November 2006

Abdominal palpation

by Dr. Howard Loomis

Part 3 -- Conclusion

This is my third and final column on abdominal palpation and its relevance to not only digestive and elimination problems but also to chronic muscle contraction and pain in the paraspinal musculature. My purpose in writing these columns has been to draw attention to how easy it is for chiropractors to become adept at diagnosing digestive complaints, which are so pervasive in our society. I have even suggested that this is an area of practice where chiropractors have no competition from the medical community.

Previously, I described the upper abdomen and its relationships and will end the trilogy in the lower abdomen this month.

Periumbilical ‑‑ the small intestine, T9 to L1

Generally, pain from the small intestine is periumbilical and poorly localized. Muscle contraction here differentiates colic (in both infants and adults) from duodenal ulceration felt in the epigastrium, jejunal dysfunction (poor disaccharide digestion) felt in the upper left quadrant, and ileal dysfunction (leaky gut, parasites, appendicitis) felt in the lower right quadrant.

Intestinal pain is frequently colicky in nature. Each wave is brief, lasting less than a minute. In between waves, the patient is symptom‑free.

The patient often feels the need to defecate, and in irritable bowel syndrome and regional enteritis, pain is relieved by bowel movement.

Intestinal obstruction is characterized by colicky pain.

Vomiting is characteristic of upper obstruction, while distention with constipation typifies lower bowel obstruction.

Persistent or continuous periumbilical colicky pain suggests acute mesenteric artery occlusion or peritonitis.

Lower right quadrant ‑‑ ileum ‑‑ cecum ‑‑ ascending colon
Lower thoracic and upper lumbar innervation

Pain emanating from the ileum, cecum, and ascending colon is usually felt in the lower right quadrant. Acute appendicitis usually begins with epigastric or periumbilical pain accompanied by nausea and vomiting. Several hours later, the pain shifts to the lower right quadrant when fever and leucocytosis become evident.

Poor protein digestion, evidenced by a high urinary indican level (so‑called "Leaky Gut Syndrome") and abdominal muscular weakness, is first evidenced in the lower right abdominal quadrant as indicated by right McBurney point tenderness or ileocecal valve stress point.

Lower left quadrant ‑‑ transverse and descending colon, L1 to L3

The afferent innervation of the colon, above the sigmoid is carried in the sympathetic trunks. Below this level, it is supplied by afferent fibers through its mesentery from the lower thoracic and upper lumbar segmental nerves, without involvement of the sympathetic or parasympathetic pathways.

Pain from the transverse and descending colon is typically located in the lower left quadrant. Because the sigmoid colon is most frequently the site of diverticula, the pain of acute diverticulitis is located in the lower left quadrant. The clinical picture has been likened to "left‑sided appendicitis."

Previous history of similar attacks, deranged bowel habits, and the absence of epigastric or periumbilical pain favor the diagnosis of diverticulitis.

The sigmoid colon ‑‑ lower lumbar

Pain from the sigmoid colon often produces posterior pain in the region of the sacrum. It may also produce pain in the suprapubic area where it may be confused with urinary bladder involvement or even a structural problem involving the 5th lumbar.

The rectum, S2 to S4

The rectum receives afferent nerves through the parasympathetic rami from S2 to S4.

Urinary bladder

Muscle contraction and palpable discomfort in the suprapubic area can also indicate urinary bladder dysfunction. This organ of elimination receives sympathetic signals from T12 to L2 and parasympathetic innervation from S2 to S4. Obviously, the case history should differentiate sigmoid colon or rectal involvement from urinary bladder.

Conclusion

Based on the information provided in this three‑part series, some general conclusions can be drawn regarding general digestive and bowel symptoms and their relationship to chronic and recurring spinal dysfunction. Coupled with a careful case history, diagnosis can be quite accurate. Muscle contractions involving visceral dysfunction will produce the paraspinal muscle contractions as noted in the accompanying table.

Once you have made a provisional diagnosis of the source of the patient's symptoms based on the case history and the above physical findings, what will your recommendations be if the cause is visceral and not structural? I would start by evaluating the patient's diet and examine to see how they are digesting it, then use plant enzymes when needed.

Next time, I will continue discussion of the Source of Stress Examination, a quick and easy examination that consistently determines the true source of a patient's symptoms. Remember, once the cause is known, the treatment becomes obvious.

(Dr. Loomis can be reached by mail at 6421 Enterprise Lane, Madison,WI 53719 or by phone at 800‑662‑2630. Visit his website at http://www.loomisenzymes.com.)