DSA1: Gastrointestinal Foundations

Originally prepared by Sharon Gustowski, DO, MPH

Revised and edited by: Ryan Seals DO
Reading Assignment(s)
1. Foundations of Osteopathic Medicine. (2010). Chila, Anthony G. Lippincott Williams & Wilkins, 3rd Edition. p.
148-154
2. This material
Learning Objectives (AOA, NBOME competencies in parenthesis next to objective)
A. Biomechanical Model
1. Recall the relevant anatomy of the gastrointestinal tract, including fascia.
2. Recall the relevant inherent motions of the gastrointestinal tract, including peristalsis and motion related to
thoracoabdominal breathing.
B. Respiratory/Circulatory Model
1. Explain physiologic arterial, venous and lymphatic circulation of the organs of the gastrointestinal tract.
C. Neurologic Model
1. Compare and contrast the physiologic actions of the sympathetic and parasympathetic nervous systems of
the gastrointestinal tract.
2. Locate the pre and post-ganglionic sympathetic and parasympathetic nervous system innervation for the
gastrointestinal organs and their major arteries.
3. Identify the physiologic action of the enteric nervous system of the gastrointestinal tract.
4. Identify the nociceptive afferent nerves to the gastrointestinal organs.
5. Describe pain referral patterns for the organs of the gastrointestinal system
D. Metabolic/Energy Model
1. Describe how the gastrointestinal system contributes to optimal cellular metabolism.
2. Identify the role the gastrointestinal tract plays in immune system function.
3. Describe the role of the gastrointestinal system in digestion and absorption of nutrients and how certain
disease states (i.e. celiac disease) can affect this process.
E. Behavioral Model
1. Analyze the relationship between psychological attitudes, emotions and behaviors and the function of the
gastrointestinal tract.

Introduction

DSA1: Gastrointestinal Foundations

Originally prepared by Sharon Gustowski, DO, MPH
Revised and edited by: Ryan Seals DO
You are what you eat
The human body is built from food. The gastrointestinal (GI) tract is composed of organs that ingest and
digest food for raw materials used in maintenance and repair of the body and for use as fuel. From the
moment that food enters the mouth, complex physiologic processes are activated, such as carbohydrate
breakdown (amylase), release of gastric acid and insulin, shunting of blood away from the muscles to the
intestines, etc. The GI tract, being open to the outside environment, provides a first-line of immune defense
against potentially harmful pathogens (by acting as a physical barrier and through immune mechanisms such
as the GALT system). It also harbors beneficial symbiotic organisms (probiotics) that have a number of
functions. The organs, mesenteries and ligaments of the GI tract are susceptible to somatic dysfunction and
treatable directly with OMT. OMT can also be use adjunctively to assist in healing of conditions such as
gastric ulcers or pancreatitis. This unit will provide background for exploration of the application of the
osteopathic tenets in the context of the five models of osteopathic medicine when the gastrointestinal tract
acquires disorders and diseases.
Biomechanical Model
Recall the relevant anatomy of the gastrointestinal tract, including fascia.
Recall the relevant inherent motions of the gastrointestinal tract, including peristalsis and motion related to
thoracoabdominal breathing.
Many organs of the gastrointestinal tract are
located in the abdomen, although some parts are
also found in the head, neck, thoracic cage and
pelvis. When the structural framework of the
abdomen is compromised by injury (including
somatic dysfunction), the organs within are also
subject to strain via direct contact or fascial
connections. Since vessels travel in the fascia,
mechanical strains can affect nutrient delivery (via
arteries) and waste removal (via veins and
lymphatics).
Additionally, direct mechanical
pressure around an organ can influence its
function.
The boney and muscular boundaries of the
abdomen are as follows: (Abdomen and Pelvis
Overview):
Superior: thoracoabdominal diaphragm, ribs: 6-12.
Posterior: Lumbar spine and related discs,
ligaments, iliopsoas, quadratus lumborum, erector
spinnae musculature.
Anterior/lateral: Rectus abdominus, transverse
abdominus, internal oblique, external oblique and
related fascia.
Inferior: pubis, ilium, ischium, muscles of the
pelvic floor.
The bony and muscular structures making up the
abdominopelvic cavity'. The anterolateral abdominal
muscles have been removed for clarity.
Abdomen and pelvis: overview and surface anatomy
Standring, Susan, PhD, DSc, FKC, Gray's Anatomy:
The Anatomical Basis of Clinical Practice, CHAPTER
60, 1041-1054 Copyright 2008 2008, Elsevier
Limited. All rights reserved.
8/4/2013

DSA3: Gastrointestinal Foundations

Originally prepared by Sharon Gustowski, DO, MPH
Revised and edited by: Ryan Seals DO
The fascias of the abdomen form specialized sacks referred to as
peritoneum, which also forms the mesenteries that suspend organs
and carry arterial, venous and lymphatic vessels. Thickened folds are
sometimes referred to as ligaments, although histologically they are not
exactly the same as ligaments that bridge joints. These sacks house and
suspend organs and create cavities within the abdomen and are
susceptible to somatic dysfunction, especially at attachment sites.
The parietal peritoneum lines most of the abdominal wall internally while
the visceral peritoneum lines the surfaces of the organs. The visceral
and parietal peritoneums form a potential space that lacks fluid but
allows for sliding motion during peristalsis, respiration, and movements
of the abdomen. The abdominal organs should be free from restriction of
motion for optimal function and unimpaired arterial, venous and
lymphatic circulation.
Some common/clinically significant fascial connections of organs to the
boney/muscular framework are:
Falciform ligament attaches to the liver and thoracoabdominal
A. Intraperitoneal. B. Retroperitoneal.
Abdomen Drake, Richard L., PhD, FAAA, Gray's
diaphragm
Basic Anatomy, 4, 133-205. Copyright 2012
Phreno-esophageal ligament attaches the esopahgus to
Copyright 2012 by Churchill Livingstone, an
diaphragm
imprint of Elsevier Inc.
Intestinal mesenteries attach to the posterior abdominal wall.
Median umbilical ligament attaches the bladder to the anterior abdominal wall.
More specific anatomy regarding individual organs will be discussed in subsequent DSAs
Biomechanical Model
Recall the relevant inherent motions of the gastrointestinal tract, including peristalsis and motion related to
thoracoabdominal breathing.

Inspiratory movements: pressure changes during

inspiration. (Adapted from Drake, Vogl and Mitchell
2005.)(Adapted from Drake, Vogl and Mitchell 2005.)
Diaphragm Standring, Susan, PhD, DSc, FKC, Gray's
Anatomy: The Anatomical Basis of Clinical Practice,
CHAPTER 58, 1007-1012 Copyright 2008

The thoracoabdominal diaphragm deserves special attention

when discussing the abdominal organs. The primary function
of the thoracoabdominal diaphragm (TAD) is for gas exchange
in the lungs and circulation of venous and lymphatic fluids.
However, the TAD also influences the organs of the
gastrointestinal tract as it contains a hiatus for the esophagus,
a n d has fascial attachments to the liver, stomach and
esophagus. Through movement, the TAD affects the motion
and position of the abdominal organs. According to one
study which directly measured TAD excursion, the lower limit
values were close to 0.9 cm for women and 1 cm for men
during quiet breathing, 1.6 cm for women and 1.8 cm for men
during voluntary sniffing, and 3.7 cm for women and 4.7 cm
for men during deep breathing (Boussages). As the TAD
descends with inhalation, it compresses the abdominal
organs inferiorly into the pelvic floor that accommodates by
descending slightly. This constant motion of the abdominal
organs is beneficial in keeping the peritoneum and
mesenteries free from restrictions to permit normal organ
function (especially peristalsis) as well as blood and
lymphatic circulation.

8/4/2013

DSA3: Gastrointestinal Foundations

Originally prepared by Sharon Gustowski, DO, MPH
Revised and edited by: Ryan Seals DO
Respiratory/Circulatory Model
Illustrate physiologic arterial, venous and lymphatic circulation of the organs of the gastrointestinal tract.
Consider the organs of the GI tract from an embryologic standpoint to understand arterial, venous and
lymphatic circulation and innervation. The GI tract is divided into the foregut, midgut and hindgut. As the organs
develop, they rotate and take along with them the corresponding, nerves, arteries, veins and lymphatics.
Foregut
Organs: esophagus, stomach, duodenum-1st and 2nd parts
(up to ampulla of Vater), liver, pancreas (portions), biliary
tract
Arterial supply: abdominal aorta celiac artery (CA)
Venous drainage: mostly splenic veinportal vein inferior
vena cava (IVC)
Lymphatic drainage: preaortic nodes near celiac artery
cysterna chyli
thoracic duct
Innervation
Preganglionic SNS: T5-9. Refer to Viscerotomal table
for specific organs.
Postganglionic SNS and some PNS: celiac ganglion,
thoracic splanchnics (T5-9)
Preganglionic PNS: vagus nerve (mostly left vagus
which remains anterior after embryologic stomach
rotation)
Midgut
Organs: distal duodenum, portions of the pancreas, jejunum,
ileum, ascending colon, proximal 2/3 of the transverse colon
Arterial supply: abdominal aorta superior mesenteric artery
(SMA)
Divisions of the gastrointestinal tract into the foregut, midgut,
Venous drainage: superior mesenteric vein
portal vein
and hindgut, summarizing the primary arterial supply to each
IVC
segment. Abdomen Drake, Richard L., PhD, FAAA, Gray's Basic
Anatomy, 4, 133-205 Copyright 2012 Copyright 2012 by
Lymphatic drainage: preaortic nodes near SMA preaortic
Churchill Livingstone, an imprint of Elsevier Inc.
nodes near CA
cysterna chyli thoracic duct
Innervation
Preganglionic SNS: T10-11, Refer to Viscerotomal table for specific organs.
Postganglionic SNS: superior mesenteric ganglion, lesser splanchnic nerves (T10-T11)
Preganglionic PNS: Vagus (posterior division, mostly from the right vagus nerve which remains
posterior after embryologic stomach rotation)
Hindgut
Organs: distal 3rd of the transverse colon, descending colon, sigmoid colon, rectum
Arterial supply: Abdominal aorta Inferior mesenteric artery (IMA)
Venous drainage: inferior mesenteric vein splenic vein portal vein
IVC. There are also veins
which anastomose with the external iliac vein IVC
Lymphatic drainage: preaortic node near IMA preaortic nodes near SMA preaortic nodes near CA

cysterna chyli thoracic duct

Innervation
Preganglionic SNS: T12-L2, Refer to viscerotomal table for specific organs
Postganglionic SNS: Inferior mesenteric ganglion. 1st and 2nd Lumbar splanchnics (L1 and L2)
Preganglionic PNS: pelvic splanchnics (S2-4) inferior hypogastric and abdominal preverterbal
plexus

8/4/2013

 DSA: Gastrointestinal Osteopathic Foundations

Originally prepared by Sharon Gustowski, DO, MPH

Revised and edited by: Ryan Seals DO

Splanchnic nerves. Abdomen. Drake, Richard L., PhD, FAAA,

Gray's Basic Anatomy, 4, 133-205 Copyright 2012 Copyright
2012 by Churchill Livingstone, an imprint of Elsevier Inc.
8/4/2013

Para-aortic lymph node groups. The main pre-aortic groups are shown. Only
the left-sided lateral nodes are shown, for clarity. Posterior abdominal wall and
retroperitoneum. Standring, Susan, PhD, DSc, FKC, Gray's Anatomy: The
ht
Anatomical Basis of Clinical Practice, CHAPTER 62, 1069-1081Copyrig4
2008 2008, Elsevier Limited. All rights reserved.

 DSA: Gastrointestinal Osteopathic Foundations

Originally prepared by Sharon Gustowski, DO, MPH

Revised and edited by: Ryan Seals DO
Neurologic Model
Compare and contrast the physiologic actions of the sympathetic and parasympathetic nervous systems of the
gastrointestinal tract.
Locate the pre and post-ganglionic sympathetic and parasympathetic nervous system innervation for the
gastrointestinal organs and their major arteries.
Identify the physiologic action of the enteric nervous system of the gastrointestinal tract.
Identify the nociceptive afferent nerves to the gastrointestinal organs.
Describe pain referral patterns for the organs of the gastrointestinal system
The following is an excerpt from: Guyton and Hall, Textbook of Medical Physiology, Twelfth Edition
John E. Hall CHAPTER 60, 729-741. Copyright 2011, by Saunders, an imprint of Elsevier Inc.
Intramural Nerve Plexus of the Gastrointestinal System
The gastrointestinal system has its own intrinsic set of nerves known as the intramural plexus or the intestinal
enteric nervous system, located in the walls of the gut. Also, both parasympathetic and sympathetic stimulation
originating in the brain can affect gastrointestinal activity mainly by increasing or decreasing specific actions in
the gastrointestinal intramural plexus. Parasympathetic stimulation, in general, increases overall degree of
activity of the gastrointestinal tract by promoting peristalsis and relaxing the sphincters, thus allowing rapid
propulsion of contents along the tract. This propulsive effect is associated with simultaneous increases in rates
of secretion by many of the gastrointestinal glands, described earlier. Normal function of the gastrointestinal
tract is not very dependent on sympathetic stimulation. However, strong sympathetic stimulation inhibits
peristalsis and increases the tone of the sphincters. The net result is greatly slowed propulsion of food through
the tract and sometimes decreased secretion as welleven to the extent of sometimes causing constipation.

Abdominal prevertebral plexus and ganglia.

Abdomen Drake, Richard L., PhD, FAAA,
Gray's Basic Anatomy, 4, 133-205
Copyright 2012 Copyright 2012 by
Churchill Livingstone, an imprint of Elsevier Inc.

8/4/2013

 DSA: Gastrointestinal Osteopathic Foundations

Originally prepared by Sharon Gustowski, DO, MPH

Revised and edited by: Ryan Seals DO

Organization of the sympathetic and parasympathetic divisions of the ANS. The left panel shows the sympathetic division. The cell bodies of
sympathetic preganglionic neurons (red) are in the intermediolateral column of the thoracic and lumbar spinal cord (T1-L3). Their axons project to
paravertebral ganglia (the sympathetic chain) and prevertebral ganglia. Postganglionic neurons (blue) therefore have long projections to their
targets. The right panel shows the parasympathetic division. The cell bodies of parasympathetic preganglionic neurons (orange) are either in the
brain (midbrain, pons medulla) or in the sacral spinal cord (S2-S4). Their axons project to ganglia very near (or even inside) the end organs.
Postganglionic neurons (green) therefore have short projections to their targets.
THE AUTONOMIC NERVOUS SYSTEM. Richerson, George B., Medical Physiology: A Cellular and Molecular Approach, CHAPTER 14, 351-370
Copyright 2012 Copyright 2012 by Saunders, an imprint of Elsevier Inc.

8/4/2013

 DSA: Gastrointestinal Osteopathic Foundations

Originally prepared by Sharon Gustowski, DO, MPH

Revised and edited by: Ryan Seals DO
Viscerosomatic Reflexes
(Review)
Nociceptors from viscera
initiate impulses that are
transmitted to the lateral
horn via sympathetic
nerves where they
synapse with
interneurons. The
stimulus is then conveyed
to both motor and
sympathetic efferents.
Almost every interneuron
receives input from both
visceral and somatic
nociceptors.
Therefore, visceral input
activates not only
sympathetic outflow but
also motor neurons that
innervate skeletal muscle.
The result is a tonic
activation of skeletal
muscles in the segmental
area of visceral input.
This reflex arc creates
increased activity at the
synapses at the cord
level; therefore the
threshold level is lowered.
It is then more easily
stimulated to discharge by
impulses of sublevel
intensity
These facilitated cord
segments may fire
sympathetic outbursts to
related organ and somatic structures- when somatic or visceral impulses pass through that region of the
cord.
Hypersympathetic activity present in almost all disease states is maintained by facilitated segment(s), and
can be influenced with OMT.
Nociceptive fibers are found mostly in the sympathetic nerves, the vagus nerve, which has mostly afferent
fibers, carries mostly non-nociceptive input, including stretch. This often initiates a viscero-visceral reflex.
Viscero-visceral reflex: Localized visceral stimuli producing patterns of reflex response in segmentally
related visceral structures
Because nociceptive fibers for abdominal organs are transmitted by SNS fibers, referred pain and
viscerosomatic reflexes overlap a great deal. Note that referred pain is a type of visceral pain and both are
poorly localized. If the parietal pleura becomes affected, pain is transmitted via somatic nerves that innervate
the abdominal wall and are better localized.

8/4/2013

 DSA: Gastrointestinal Osteopathic Foundations

Originally prepared by Sharon Gustowski, DO, MPH

Revised and edited by: Ryan Seals DO

The following is an excerpt from: Medical Physiology: A Cellular and Molecular Approach ,
Updated Second Edition Walter F. Boron, and Emile L. Boulpaep CHAPTER 14 , 351-370
Copyright 2012 by Saunders, an imprint of Elsevier Inc.
The visceral control system also has an important afferent limb
All internal organs are densely innervated by visceral afferents. Some of these receptors monitor
nociceptive (painful) input. Others are sensitive to a variety of mechanical and chemical
(physiological) stimuli, including stretch of the heart, blood vessels, and hollow viscera, as well as P CO
2, P O 2, pH, blood glucose, and temperature of the skin and internal organs. Many visceral nociceptive
fibers travel in sympathetic nerves (blue projections in Fig. 14-2). Most axons from physiological
receptors travel with parasympathetic fibers. As is the case with somatic afferents, the cell bodies of
visceral afferent fibers are located within the dorsal root ganglia or cranial nerve ganglia (e.g., nodose
and petrosal ganglia). Ninety percent of these visceral afferents are unmyelinated.
The largest concentration of visceral afferent axons can be found in the vagus nerve, which carries
non- nociceptive afferent input to the CNS from all viscera of the thorax and abdomen. Most fibers in the
vagus nerve are afferents, even though all parasympathetic preganglionic output (i.e., efferents) to the
abdominal and thoracic viscera also travels in the vagus nerve. Vagal afferents, whose cell bodies are
located in the nodose ganglion, carry information about the distention of hollow organs (e.g., blood
vessels, cardiac chambers, stomach, bronchioles), blood gases (e.g., P O 2, P CO 2, pH), and body
chemistry (e.g., glucose concentration) to the medulla. Internal organs also have nociceptive receptors
that are sensitive to excessive stretch, noxious chemical irritants, and very large decreases in pH. In the
CNS, this visceral pain input is mapped viscerotopically at the level of the spinal cord because most
visceral nociceptive fibers travel with the sympathetic fibers and enter the spinal cord at a specific
segmental level along with a spinal nerve ( Fig. 14-2). This viscerotopic mapping is also present in the
brainstem but not at the level of the cerebral cortex. Thus, awareness of visceral pain is not usually
localized to a specific organ n but is instead referred to the dermatome that is innervated by the same
spinal nerve.
Primary sensory sympathetic afferent fibers ( red
) shown in relation to posterior horn tract cells ( green )
conveying visceral information to the thalamus and to
general visceral efferent neurons ( blue ).
Viscerosensory Pathways Naftel, J.P., Fundamental
Neuroscience for Basic and Clinical Applications,
Chapter 19, 260- 266.e1. Copyright 2013 Copyright
2013 by Saunders, an imprint of Elsevier Inc.

8/4/2013

 DSA: Gastrointestinal Osteopathic Foundations

Originally prepared by Sharon Gustowski, DO, MPH

Revised and edited by: Ryan Seals DO

Superficial areas to which pain is

commonly referred from the
corresponding deep structures.
Naftel, J.P. - Fundamental
Neuroscience for Basic and Clinical
Applications, 260-266.e1
2013 Copyright 2013 by
Saunders, an imprint of Elsevier
Inc.

8/4/2013

 DSA: Gastrointestinal Osteopathic Foundations

Originally prepared by Sharon Gustowski, DO, MPH

Revised and edited by: Ryan Seals DO

Metabolic/Energy Model
Identify how the gastrointestinal system contributes to optimal cellular metabolism.
Identify the role the gastrointestinal tract plays in immune system function.
Describe the role of the gastrointestinal system in digestion and absorption of nutrients and how certain disease
states (i.e. celiac disease) can affect this process.

The GI system is influenced by numerous hormones and peptides, and many substances are released
from organs at different stages in the digestive process. When properly functioning, the GI tract
digests and assimilates nutrients for conversion into fuel, creation of cells and cellular repair and cellular
action. GI organ irritation or injury can lead to dysregulation of these substances and subsequently
impair digestion, causing numerous effects. Please review GI physiology in the Systems course for
complete details. Below is an excerpt on Celiac disease that gives a good illustration about how the
structure of the intestinal mucosa and villi affect function (i.e. nutrient absorption).
From Netter's Gastroenterology , Second Edition. MARTIN H. FLOCH. Ch 112, 289-293
Copyright 2010 by Saunders, an imprint of Elsevier Inc.

Gluten enteropathy, or celiac disease, is a malabsorption syndrome that results from gluten-sensitive
damage to the intestinal microvilli and villi, producing an abnormal villous architecture and resulting in
malabsorption. This disease process exemplifies the classic signs and symptoms of malabsorption
disorders. When a person with gluten enteropathy ingests gluten, the epithelium becomes damaged, the
cellular maturation of epithelial cells of the villus becomes disturbed, the small bowel mucosa becomes
inflamed, and mild villous atrophy to total loss of villi results in atrophic-looking mucosa.
Understanding this classic disease entity leads to an understanding of small bowel function and all its
possible diseases. Almost all manifestations of abnormal digestion and absorption and all systemic
manifestations, from skin disorders to malignancy, are associated with celiac disease.
The cardinal presentation of weight loss associated with steatorrhea is seen only occasionally. The
clinician should check for celiac disease in the current environment of plentiful food when a patient
experiences anemia, osteoporosis, unexplained diarrhea, or any vitamin deficiency, even if weight loss is
not apparent. With the availability of numerous serologic tests, latent celiac disease has become more
apparent in patients with such conditions as occult anemia, osteoporosis, and some associated
malignancies.
Serum testing has improved the ability to make an early diagnosis of celiac disease and malabsorption
syndrome. Immunoglobulin A (IgA) endomysial antibodies and IgA tissue transglutaminase antibodies
have reached almost 98% sensitivity and specificity. IgA and IgG antigliadin antibodies are less sensitive
and less specific but more helpful. The standard for diagnosing celiac disease is to demonstrate the
histologic lesions on small bowel biopsy
The treatment for celiac disease is a gluten-free diet. There is no other treatment. Removing all gluten
from the diet is essential.

10

8/4/2013

 DSA: Gastrointestinal Osteopathic Foundations

Originally prepared by Sharon Gustowski, DO, MPH

Revised and edited by: Ryan Seals DO
Behavioral Model
Analyze the relationship between psychological attitudes, emotions and behaviors and the function of
the gastrointestinal tract.
The effect of attitudes, emotions and behaviors on the GI tract are extensive. What type of and how much
food an individual chooses may or may not be in that persons control. Many people in the world go hungry
and even die from lack of food, or food with enough nutrients. Thus, consideration of the behavioral model
as it applies to the GI system begins with a complete understanding of each patients circumstances
surrounding their food source.
In the U.S.A. there is an obesity epidemic, which leads to numerous other diseases such as
hypertension, diabetes, and cardiovascular disease- all conditions which require the attention of a physician,
and can lead to diminished quality of life and death. Now more than ever, physicians must educate
themselves and their patients on proper nutrition. Education of patients on how to change unhealthy
behaviors is best done in an individualized, supportive fashion.
The GI tract, not only handles and processes a persons food choices, is also reactive and sensitive to
emotional stress and attitudes. Disorders in the GI tract most related to emotions and attitudes are called
Functional GI disorders- those diseases in which no physical pathology can be found, yet the patient
experiences abnormal function, such as recurrent diarrhea. Entire textbooks are devoted to this unique
category of diseases, and specific diseases will be addressed in subsequent DSAs.
The following is an excerpt from: FUNCTIONAL GASTROINTESTINAL DISORDERS: IRRITABLE BOWEL
SYNDROME, DYSPEPSIA, AND FUNCTIONAL CHEST PAIN OF PRESUMED ESOPHAGEAL ORIGIN.
Mayer, Emeran A., Goldman& Cecil Medicine , Twenty-Fourth Edition, 139, 868-874 Copyright by
Saunders, an imprint of Elsevier Inc.
FUNCTIONAL GASTROINTESTINAL DISORDERS DEFINITIONS
Irritable bowel syndrome (IBS), functional dyspepsia, and functional chest pain of presumed esophageal
origin are characterized by chronic, recurrent symptoms of pain and discomfort referred to the lower
abdomen, the epigastrium and upper abdomen, and the retrosternum, respectively. They belong to the
family of functional gastrointestinal (GI) disorders that comprise a wide spectrum of chronic GI disorders
common in both the adult and pediatric populations. In the absence of disease-specific biomarkers, each
syndrome is classified by symptoms and the absence of other conditions that can account for the
symptoms. Despite the benign prognoses, functional GI diseases can affect health-related quality of life at
least as much as organic diseases. PATHOBIOLOGY
The pathophysiology of functional GI diseases remains incompletely understood, but these diseases are
characterized by alterations in bidirectional interactions between the brain and the gut (brain-gut axis; EFig. 139-1), with variable contributions of enhanced perception of visceral signals by the central nervous
system (visceral hypersensitivity) and altered signaling from the nervous system to the GI tract, through
autonomic nervous system activity. Each diagnostic category of functional GI disease is defined by
symptomatic criteria that include different subsets of patients who exhibit different patterns of the braingut axis dysregulation and that result in varying abnormalities in GI motility, secretion, immune function,
or visceral sensitivity. Despite this heterogeneity, however, functional GI diseases all share certain
f eatures, including enhanced sensitivity to stress, the frequent coexistence of psychiatric and chronic
pain disorders, an enhanced perception of visceral events, and a greater prevalence in women.

11

8/4/2013

 DSA: Gastrointestinal Osteopathic Foundations

Originally prepared by Sharon Gustowski, DO, MPH

Revised and edited by: Ryan Seals DO

12

 DSA: Gastrointestinal Osteopathic Foundations

Originally prepared by Sharon Gustowski, DO, MPH

Revised and edited by: Ryan Seals DO
Enhanced Perception of Visceral Pain
About 30 to 70% of patients with functional GI diseases have an altered perception of visceral afferent stimuli
(visceral hypersensitivity), in which normally innocuous stimuli, such as physiologic contractions, distentions,
or chemical stimulation of the intestine, stomach, or esophagus, lead to the sensation of pain or discomfort.
The stimulus may be spontaneous peristaltic activity or result from distention by luminal contents, such as
ingested food, liquids, gas, or feces. Visceral hypersensitivity may be associated with aberrant referral of
visceral sensations to a particular body area, and this referral is often atypical in location and larger compared
with most individuals.
Altered Stress Responsiveness
Abnormal autonomic and neuroendocrine responses to psychosocial stressors are a key feature of functional
GI disease and may play an important role in both its cause and its exacerbation. For example, stressful
events are more likely to lead to abdominal pain and a change in stool pattern in patients with IBS compared
with healthy controls, and stress has been correlated with bowel symptoms and physician visit. Data also
support an association between stress and functional dyspepsia. Patients with functional GI disease report
more lifetime stressful events than healthy controls, and this early life stress may interact with a genetic
predisposition to determine the vulnerability of an individual to adult stressors and the subsequent
development of functional GI diseases.

13

 DSA: Gastrointestinal Osteopathic Foundations

Originally prepared by Sharon Gustowski, DO, MPH

Revised and edited by: Ryan Seals DO

14

 DSA: Gastrointestinal Osteopathic Foundations

Originally prepared by Sharon Gustowski, DO, MPH

Revised and edited by: Ryan Seals DO

15