August 2007

Abdominal palpation III

by Dr. Howard Loomis

The "second factor" in chiropractic examination is designed to indicate when visceral dysfunction is the underlying cause and perpetuating a musculoskeletal problem. We know that structure and function cannot be separated when attempting to find the cause of a patient's symptoms and that anatomy strongly influences physiology and vice versa. Of course, they are unquestionably linked neurologically. Last month, I discussed those relationships and how often functional or visceral symptoms correlate directly with structural imbalances. The trick is to know which is the cause and which the effect. In this regard, the importance of the abdominal examination cannot be overestimated.

Position of the patient

The patient should be supine and relaxed, with a small pillow beneath the head and the arms folded across the chest. Adequate relaxation is necessary, and the patient should be assured that no sudden or painful procedure will be carried out.

It is important to have the patient localize areas of pain or discomfort; unfortunately, many abdominal problems are poorly localized. So we examine in a systematic manner and begin our palpating for obvious abdominal muscle contraction in the epigastrium, that area in the midline below the xiphoid process.

Epigastrium ‑‑ The esophagus (T5‑T6)

Pain impulses arising in the esophagus are carried by afferent nerve fibers through the sympathetics and enter the spinal cord from the level of the lower cervical through the entire thoracic vertebrae. The 5th and 6th thoracic spinal segments are the most frequent. Esophageal pain corresponds relatively well to the site of irritation:

***  Upper esophagus = pain in the suprasternal notch or beneath the manubrium

***  Mid‑esophagus = beneath the mid‑sternum

***  Lower esophagus = beneath the xiphoid process or in the epigastrium

The most common pain in the esophagus is "heartburn," a burning pain felt substernally and well‑localized over the site of irritation. This pain has been shown to be a spasm of the cardiac end of the esophagus.

Epigastrium ‑‑ The stomach (T7‑T9)

Studies have shown that pain of considerable intensity is produced by either mechanical or chemical stimulation of the gastric mucosa when it is inflamed, congested, or edematous. Structures covered by the mucosal lining can give rise to painful sensations when the stomach vigorously contracts, especially if the wall is inflamed. Afferent impulses enter the cord at the level of the 7th to 9th dorsal roots. Pain of gastric origin may also be felt in the upper left quadrant.

Epigastrium ‑‑ The duodenum (T9‑T11)

Impulses from the small intestine travel in splanchnic pathways and enter the cord from T9‑T11, lower than those of the stomach. Peptic ulcer of the duodenum is most often experienced in the epigastrium, usually in the mid‑line. This pain typically begins 1 to 2 hours after eating and is relieved by eating or antacids. A change of any kind in this pattern is suggestive of penetration into neighboring structures, such as the pancreas. This pain will not be relieved by food or antacids.

Upper right quadrant ‑‑ Gallbladder and liver (T4‑T9)

The pain of biliary tract origin is usually experienced along the distribution of T8 or T9 and in the upper right quadrant. In acute cholecystitis, the right upper quadrant pain is most characteristic. Pain referred posteriorly to the angle of the scapula suggests a stone impacted in the cystic duct. Occasionally, pain may be referred to the shoulders via the phrenic nerve.

It is common to obtain a history of pain onset several hours after ingestion of a large meal. During an attack, pain gradually builds in intensity, and while it will wax and wane, it does not entirely disappear until the attack is over. Tenderness and muscle rigidity in the upper right quadrant are common. The patient is febrile and appears toxic. The passage of gallstones through extrahepatic bile ducts typically gives rise to BILIARY COLIC which is evidenced by sudden, intense, paroxysmal pain. It is usually more localized than pain of cholecystitis, but also found in the anterior right upper quadrant and/or posteriorly in the subscapular areas. Biliary colic is most frequently accompanied by vomiting and less often by muscular rigidity as in cholecystitis. Gallstones lodged in the common duct may not cause pain, but rather recurrent fever and chills (Charcot's Fever).

Upper left quadrant ‑‑ The jejunum (T9‑L1)

Problems arising in the jejunum are usually palpated in this quadrant. Celiac disease (non‑tropical sprue or idiopathic steatorrhea) is one of the hereditary malabsorption syndromes. It is characterized by cramping pain and large, pale, fatty, bulky stools. Often, diarrhea is a feature. There is typical histologic alteration of the jejunal mucosa caused by a deficiency of one or more of the peptide‑hydrolyzing enzymes that complete the digestion of the simple sugars. Generalized disaccharidase deficiency occurs, causing poor absorption of lactose, sucrose, and maltose.

(Dr. Loomis can be reached by mail at 6421 Enterprise Lane, Madison, WI 53719 or by phone at 1‑800‑662‑2630. Visit his website at http://www.loomisenzymes.com.)