Free
OMT Minute  |   July 2019
Mesenteric Lift for Constipation in Cystic Fibrosis
Author Notes
  • From the Touro University College of Osteopathic Medicine-CA in Vallejo. 
  • Financial Disclosures: None reported. 
  • Support: This video was produced by Touro University College of Osteopathic Medicine-CA. 
  •  *Address correspondence to Kimberly Wolf, DO, 1310 Club Dr, Mare Island, Vallejo, CA 94592-1187. Email: kimberly.wolf@tu.edu
     
Article Information
Osteopathic Manipulative Treatment / Pulmonary Disorders
OMT Minute   |   July 2019
Mesenteric Lift for Constipation in Cystic Fibrosis
The Journal of the American Osteopathic Association, July 2019, Vol. 119, e36-e37. doi:https://doi.org/10.7556/jaoa.2019.085
The Journal of the American Osteopathic Association, July 2019, Vol. 119, e36-e37. doi:https://doi.org/10.7556/jaoa.2019.085
  
Osteopathic Manipulative Treatment for Constipation in Patients With Cystic Fibrosis
eVideo. Dr Wolf demonstrates the use of a mesenteric lift to improve symptoms of constipation in patients with cystic fibrosis.
Cystic fibrosis is an autosomal recessive genetic disorder caused by a mutation in the cystic fibrosis transmembrane regulator (CFTR) gene.1 This gene codes for a protein that is an active transport channel for chloride across cell membranes and is involved in the regulation of mucus and fluid consistency across several systems, including the gastrointestinal tract.1 As the movement of water and salt across the cellular membranes is decreased, mucus produced by the gastrointestinal system thickens and the composition of gastrointestinal fluid is altered, leading to slow colonic transit and constipation.1 This condition, which often causes discomfort, abdominal pain, and abdominal distension in patients with cystic fibrosis, also increases the risk for serious complications such as bowel obstruction and bowel perforation.2 
The small intestine includes the duodenum, jejunum, and ileum. Along with a portion of the cecum, it is suspended from the posterior abdominal wall by the small bowel mesentery or the root of the mesentery. This mesentery is found running on an oblique angle from left to right from the left L2 vertebral body to the right sacroiliac joint.3 The large intestine begins at the ileocecal valve and consists of the cecum and ascending, transverse, descending, sigmoid, and rectal portions. The ascending and descending colon and rectum are normally in a secondarily retroperitoneal location, whereas the cecum and transverse and sigmoid colon are suspended from the posterior abdominal wall by the small bowel mesentery, transverse mesocolon, and sigmoid mesocolon, respectively.3 These mesenteries function as conduits for the vasculature, nerves, and lymphatic tissues serving the large bowel. 
The large intestine receives both intrinsic and extrinsic innervation. The intrinsic system or enteric nervous system is represented by a network of nerve fibers that form the myenteric plexus of Auerbach and the submucosal plexus of Meissner. Extrinsic innervation for the proximal large bowel, up to the splenic flexure, consists of sympathetic neurons that arise from the lateral horn of the spinal cord in the T5-12 spinal levels, and parasympathetic fibers, which originate from the vagus nerve.3 The descending and sigmoid colon and rectum receive sympathetic innervation from the lumbar splanchnic nerves (L1-2) through the inferior mesenteric ganglion and sacral splanchnic nerves that ascend from the pelvis in the superior and inferior hypogastric plexuses.3 Parasympathetic innervation to this area originates in the spinal cord at levels S2-4 and exits the ventral rami pelvic splanchnic nerves, also ascending through the hypogastric plexuses.3 
Literature has shown that osteopathic manipulative treatment (OMT) can provide benefits in patients with common gastrointestinal ailments such as irritable bowel syndrome, postoperative ileus, diabetic gastroparesis, chronic constipation, and colonic inertia.4-9 These studies showed how OMT techniques, such as direct myofascial release, visceral manipulation, osteopathic cranial manipulative medicine, and autonomic nervous system balancing, may influence peristalsis and colonic transit time and provide symptomatic relief. This evidence suggests that OMT may be beneficial for patients with cystic fibrosis who have constipation. 
An OMT technique that can be easily and safely performed in this patient population to potentially aid in the regulation of large bowel congestion, circulation, and motility is the mesenteric lift (video).10 
Contraindications or special considerations to visceral treatment include severe abdominal pain (suggesting an acute abdominal process), abdominal aortic aneurysm, infections, metastatic processes, internal bleeding, recent abdominal surgery, and inability of the patient to tolerate the treatment.11 
Many patients with cystic fibrosis rely on a regimen of laxatives to avoid constipation.1 Adjunctive therapy with OMT may provide relief of symptoms, promote colonic motility, and decrease the rate of serious complications. The technique demonstrated in this video is not intended to treat any specific clinical condition but is only one aspect of the diagnosis and treatment plan an osteopathic physician may use to address the whole patient. 
Acknowledgments
We thank Jeff Reedy for video contributions and Kathleen Winger, OMS II, for serving as the patient in the video. 
References
Van der Doef HP, Kokke FT, Beek FJ, Woestenenk JW, Froeling SP, Houwen RH. Constipation in pediatric cystic fibrosis patients: an underestimated medical condition. J Cyst Fibros. 2010;9(1):59-63. [CrossRef] [PubMed]
Assis DN, Freedman SD. Gastrointestinal disorders in cystic fibrosis. Clin Chest Med. 2016;37(1):109-118. [CrossRef] [PubMed]
Moore KL, Dalley AF, Agur AM. Clinically Oriented Anatomy. 8th ed. 2018:268-276.
Müller A, Franke H, Resch KL, Fryer G. Effectiveness of osteopathic manipulative therapy for managing symptoms of irritable bowel syndrome: a systematic review. J Am Osteopath Assoc. 2014;114(6):470-479. [CrossRef] [PubMed]
Stiedl M, Müller A, Salomon J, Schwerla F, Resch KL. Osteopathy as a promising short-term strategy for irritable bowel syndrome: randomised controlled trial. Focus Altern Compl Ther. 2003;8(4):536. [CrossRef]
Baltazar GA, Betler MP, Akella K, Khatri R, Asaro R, Chendrasekhar A. Effect of osteopathic manipulative treatment on incidence of postoperative ileus and hospital length of stay in general surgical patients. J Am Osteopath Assoc. 2013;113(3):204-209. [PubMed]
Ravenswaay VJ Van, Hain SJ, Grasso S, Shubrook JH. Effects of osteopathic manipulative treatment on diabetic gastroparesis. J Am Osteopath Assoc. 2015;115(7):452-458. doi: 10.7556/jaoa.2015.091 [CrossRef] [PubMed]
Brugman R, Fitzgerald K, Fryer G. The effect of osteopathic treatment on chronic constipation—a pilot study. Int J Osteopath Med. 2010;13(1):17-23. doi: 10.1016/j.ijosm.2009.10.002 [CrossRef]
Cohen-Lewe A. Osteopathic manipulative treatment for colonic inertia. J Am Osteopath Assoc. 2013;113(3):216-220. [PubMed]
Wallace E, McPartland JM, Jones JM III, Kuchera WA, Buser BR. Lymphatic system: lymphatic manipulative techniques. In: Ward RC, executive ed. Foundations for Osteopathic Medicine. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2003:1074-1075.
Heinking KP, Kappler RE. Pelvis and sacrum. In: Chila AG, executive ed. Foundations of Osteopathic Medicine. 3rd ed. Baltimore, MD: Lippincott Williams & Wilkins; 2011:853-864.
  
Osteopathic Manipulative Treatment for Constipation in Patients With Cystic Fibrosis
eVideo. Dr Wolf demonstrates the use of a mesenteric lift to improve symptoms of constipation in patients with cystic fibrosis.