Student Handout

GI ILS

INTEGRATIVE LEARNING SESSION: GI SYSTEM

NOTE TO STUDENTS: This GI ILS consists of two parts:

A small-group session, where you will be expected to discuss a case presentation and
present information based on discussion questions that will be provided.
An OMM lab session, where you will be able to synthesize information presented so far
in the ECM and OPP courses into an approach to the evaluation of a patient with a GI
complaint.

You have already been presented with a great deal of information regarding the GI system, as
listed in the learning objectives given below. There are also resources available in the OMM
Resources section of Blackboard. These are all resources for you to use as you need or wish
with this ILS, but you will not be expected to spend hours reading and re-reading all of this
information. If you wish to target some core material that should assist you in the case
discussion, answering the discussion questions, participating in the Blackboard exercise, and in
the OMM lab exercise, we suggest the following:
Primary Resources: This is the primary information for use with the case study and discussion
questions:

Clinical applications of osteopathic philosophy and principles to the gastrointestinal

system (posted on Blackboard in the OPP IV course documents section)
Doctor Giustis PowerPoint from the GI System I, II and III OMM lab sessions

The following article is posted on Blackboard, and is REQUIRED READING for this ILS:
Crow TW, Gorodinsky L. Does osteopathic manipulative treatment (OMT) improve outcomes
in patients who develop postoperative ileus: A retrospective chart review. International Journal
of Osteopathic Medicine 12 (2009) 32-37. doi:10.1016/j.ijosm.2008.03.004
Additional Resources:

Kuchera ML, Kuchera WA. Osteopathic Considerations in Systemic Dysfunction, 2nd

Ed., Columbia, OH: Greyden Press 1994.

Good luck and have fun!

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Student Handout GI ILS

Learning Objectives for GI ILS

Using the information learned from the following resources:
1. ECM lectures and standardized patients encounters
2. OPP course lectures, labs and material:

GI system I, II and III (S2426)

Hospital Screening Exam (S18)
Inpatient OMM I (S19)
Post Op Complications I and II (S20S21)
Chapmans Reflexes Lab (S23)
OMM resources on Blackboard

3. Pertinent info from other systems courses (including but not limited to: Gastrointestinal,
Reproductive, Musculoskeletal)

Given an example case, the student will be able to:

Take an appropriate patient history

Perform a focused PE for a patient presenting with nonspecific, persistent GI complaints
such as nonsevere pain and inconsistent bowel habits
Using the five models approach, list a differential diagnosis for a patient presenting with
abdominal pain.
Describe an appropriate treatment plan for the patient described in the case presentation
below, including the use of OMT
Describe the indications, contraindications and rationale for the use of OMT for patients
such as the one described in the case presentation
Describe the diagnosis and medical and/or surgical treatment of this patient
List the possible complications associated with this patients condition (using the five
models to evaluate how this condition affects the whole person)
Identify and list literature sources related to the osteopathic approach to the GI system and
this patients condition
Given a written exam, be able to answer, to a 70% or greater competency level, questions
about the osteopathic approach to clinical situations such as the one presented here
Given a competency testing situation, be able to demonstrate, to a 70% or greater
competency level, the performance of the following OMT techniques:
CV4
Paraspinal inhibition
Collateral ganglia inhibition
Linea alba/falciform ligament release
Cecum and sigmoid lift/release
Root of mesentery lift/release
Chapmans reflex points related to the appendix, colon, small bowel

Student Handout GI ILS

CASE PRESENTATION
DISCLOSURE 1
Setting: Emergency Department (ED)
CC: Abdominal Pain

HPI: A 72 year old female presents to the ED with abdominal pain. The pain began this morning
in the epigastric and right upper quadrant (RUQ) areas. She tried taking some antacids and
later, acetaminophen, but the pain persisted. She feels that her pain may be related to fatty
meals. Recent history includes episodic pain 2 days ago that had resolved until this
morning. She describes the pain as a constant heavy ache. The pain radiates into her back
and varies in severity. Her pain peaked this morning at about 8 AM and lasted for about 2
hours. She rates the severity of the pain as 10 out of 10. The pain receded and was minimal
(12 out of 10) for most of the day, but has peaked to 10 out of 10 again this evening. She
has a decreased appetite today and had to cancel shopping with her daughter due to her
abdominal pain. She has no history of gallbladder or pancreatic disease.

Allergies:
No known allergies.

Medications:
Chlorthalidone
(50mg PO qd)
Fenofibrate
(145mg PO qd)
Valsartan

(80mg PO qd)
Alprazolam
(0.25mg PO qd)
Furosemide
(40mg PO bid)
Acetamenophen
(325mg PO qid)

PMH:

Hypertension
Hypercholesterolemia
Anxiety
Migraine headaches
Osteoarthritis
Insomnia
Spinal Stenosis
Obstructive sleep apnea for which she uses CPAP

Surgical Hx:
Appendectomy as a child

Family Hx:
Heart disease in maternal grandfather & mother
Cancer (breast) in paternal grandmother
Dementia in father

Social:
The patient denies smoking or illicit drug use, but does admit to an occasional
alcoholic drink. She has no primary doctor since her previous doctor retired a
few years ago. She is married and has two children; a son and a daughter.

Student Handout GI ILS

ROS:

General: Denies fever, chills, or night sweats.
SKIN: Denies rashes, new or concerning lesions.
HEENT: Otitis media 2 weeks ago, seen in the ED, and prescribed amoxicillin. Denies
continued symptoms. No history of head trauma. Denies visual problems. Last
vision exam 5 years ago, no glasses. Denies nasal congestion, rhinorrhea, or
sneezing often.
NECK: Denies history of thyroid disease or trauma to the neck
CV: Denies chest pain on exertion, palpitations, or cold extremities. Positive history of
HTN, hypercholesterolemia, and mild edema
RESP: Denies cough, hemoptysis, or shortness of breath. No history of pneumonia.
GI: See HPI. Patient complains of decreased appetite today due to upper abdominal
pain radiating to the back. Denies nausea, vomiting, diarrhea, constipation,
hematemesis, hematochezia, and melena. Denies history of ulcers. Patient claims
that stool is of normal color, volume, frequency and consistency.
GU: Denies hematuria, urgency, frequency, or dysuria.
OB/GYN: Gravida 2, Para 2; last pap 7 years ago, was normal; does monthly selfbreast
exams, post menopausal
MSK: Patient complains of chronic knee pain related to osteoarthritis controlled with
scheduled acetaminophen. No history of fractures, loss of consciousness, or
trauma. Occasional bilateral low back pain radiating down her legs, worse with
walking or standing for long periods.
ENDO: Denies changes in overall energy or weight, heat or cold intolerance, polyuria,
polydipsia, or polyphagia.
NEURO: Denies headache or other neurologic symptoms. Patient denies motor or sensory
deficits
PSYCH: History of anxiety, never hospitalized. Does not see a psychiatrist and denies
suicidal ideation or plan, racing thoughts, spending sprees, loss of motivation, or
changing interests. Patient does report sporadic mild insomnia, not currently an
issue.

OBJECTIVE

Vitals signs: BP = 149/71, HR = 81, RR = 16, O2 Sat = 99% on room air, Temp = 98.2
General: Alert and oriented X 3 to person, place, and situation. WDWN, appears stated age.
Patient appears to be in moderate distress, but is polite and cooperative, despite
obvious anxiety.
HEENT: NCAT, PERRL, EOM patent and TM intact bilaterally; oropharynx is without
erythema, and mucus membranes are moist without lesions.
Neck: Supple and nontender; no adenopathy; trachea is midline and no thyromegaly
noted on exam.
Heart: RRR, no abnormal heart sounds noted with auscultation.
Lungs: CTA bilaterally. No wheezes, crackles, or rhonchi; mildly decreased depth of
breathing.
Abdomen: Abdomen is obese but otherwise appears normal and nondistended. Normal
bowel sounds are present in all 4 quadrants. Abdomen is soft throughout with

Student Handout GI ILS

tenderness noted in the epigastrium and RUQ. Pain is 34 out of 10 with

palpation of her abdomen. Murphys sign is negative. No masses are noted on
deep palpation of the abdomen. No rebound tenderness and no guarding found in
the examination. The lower abdomen examination is unremarkable.
Extremities: warm, well perfused and without tenderness. Mild pedal edema noted.
Neurologic: CN IIXII intact bilaterally; sensation intact in UE bilaterally & LE bilaterally; no
focal findings
Derm: Normal color without erythema, jaundice, rash, or bruising.
Osteopathic: Gait is slow and rigid, overall posture is anterior; patient stands with slight
flexion at the waist (noted as patient is ambulating to the examination room);
mild to moderate genu valgum; paraspinal muscles are hypertonic bilaterally in
the mid to lower thoracic region. Positive Chapmans reflexes are noted
bilaterally in the 9th and 10th intercostal spaces.
- SBS compression; CRI is increased to 20/minute
- OA E RLSR; AA RR; C4 E RRSR; C6 E RLSL
- T 79 N RRSL
- Diaphragm restricted bilaterally, L > R
- L2 FRLSL; L5 N RRSL
- Left on left sacral torsion

Lab results:

CBC
WBC
RBC
Hgb
Hct
MCV
MCH
MCHC
RDW
Plts

10.2
4.43
11.7
37.6
84.9
26.4
31.1
12.4
292

BloodChemistry
Na
135
K
3.8
Cl
100
HCO3
24.5
Anion Gap
14
Glucose
208
BUN
29
Creatinine
1.3
BUN/CR ratio
22
MDRD GFR
40
Ca
9.5
Adjusted Ca
9.8
Total Protein
7.0
Albumin
3.8
AST
15
ALT
18
Total Bilirubin
0.3
Amylase
35
Lipase
27

UrineCleanCatch
Color
Yellow
Clarity
Clear
Spec. Gravity
1.015
Urine pH
5.0
LE
Negative
Nitrite
Negative
Protein
Negative
Glucose
Normal
Ketones
Negative
Urobilinogen
Normal
Bilirubin
Negative
Blood
Negative

Chest Xray was without evidence of an acute disease and EKG was negative for ischemic
changes. Ultrasound also was performed with benign findings of steatohepatosis and a

Student Handout GI ILS

pancreatic duct measuring in the upper limits of normal; however, there was no evidence of
any acute disease.

DISCUSSION QUESTIONS
1. Using the five models as a guide, create a differential diagnosis for this patient.

2. What possible viscerosomatic relationships might be involved in this patient
(i.e., what segmental relationships are there with the various abdominal
organs?) How can this knowledge help you with your evaluation of the
patient?

3. What is the next best step in this patients evaluation and care?


NOTE: After discussing the questions above, a second disclosure will be presented to you
by your facilitator.

DISCUSSION QUESTIONS (continued)

4. Describe how you would examine this patients abdomen, including any osteopathic
components.
5. Using the Five Models as a guide, create a treatment plan for this patient, to be
followed during her hospital stay.
6. If you had the opportunity to provide OMT for this patient preoperatively, what
would be the treatment goals for the OMT? What
7. What are some possible complications this patient might experience? How can OMT
play a role in preventing such complications, or treating them if they occur?