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Original Contribution  |   September 2020
Clinical Efficacy of Mesenteric Lift to Relieve Constipation in Traumatic Brain Injury Patients
Author Notes
  • From the Arrowhead Regional Medical Center in Colton, California (Dr J.A.D. Berry); the Riverside University Health System (Neurosurgery Residency Program) in Moreno Valley, California (Drs Ogunlade, Kashyap, Wacker, and Miulli); the American Osteopathic Board of Preventive Medicine in Olathe, Kansas (Dr D.K. Berry); and Allegheny General Hospital (Neurology Residency Program) in Pittsburgh, Pennsylvania (Dr Saini). 
  • Financial Disclosures: None reported. 
  • Support: None reported. 
  •  *Address correspondence to James A.D. Berry DO, 26520 Cactus Ave, Moreno Valley, CA 92555-3927. Email jamesberrydo@gmail.com
     
Article Information
Emergency Medicine / Neuromusculoskeletal Disorders / Osteopathic Manipulative Treatment
Original Contribution   |   September 2020
Clinical Efficacy of Mesenteric Lift to Relieve Constipation in Traumatic Brain Injury Patients
The Journal of the American Osteopathic Association, September 2020, Vol. 120, 597-600. doi:https://doi.org/10.7556/jaoa.2020.094
The Journal of the American Osteopathic Association, September 2020, Vol. 120, 597-600. doi:https://doi.org/10.7556/jaoa.2020.094
Abstract

Context: Patients with severe traumatic brain injury (TBI) often have multiple autonomic disturbances that interfere with normal gastrointestinal motility. Many of the pharmacologic agents used in the intensive care unit (ICU) also adversely affect gastrointestinal motility. The body is further subjected to excessive levels of sympathetic discharge in states of traumatic injury and extreme stress, which can interfere with the proper absorption of fluids and nutrients.

Objective: To determine whether mesenteric lift, an osteopathic manipulative treatment technique, is effective in relieving constipation in patients with TBI who are intubated in the ICU.

Methods: This retrospective medical record review examined the effect of mesenteric lift on intubated patients with significant TBI who were unable to have a bowel movement within 72 hours of admission. The primary endpoint was the return of normal bowel function within 24 hours. A control group consisted of intubated patients with TBI during the same period who did not receive mesenteric lift.

Results: Of patients who received mesenteric lift, 77% experienced bowel movements (n=27 of 35), compared with 36% (n=16 of 44) in the control group (P=.01).

Conclusion: The application of mesenteric lift to intubated patients with severe TBI in the intensive care unit significantly increased patients’ ability to resume normal bowel function and expel waste.

Patients with severe traumatic brain injury (TBI) often require intubation and admission to the intensive care unit (ICU). They have multiple autonomic disturbances that interfere with normal gastrointestinal (GI) motility associated with a hyper-sympathetic response due to a surge of catecholamines, which have an inhibitory effect on the neurons of the enteric nervous system by decreasing the motility in the smooth muscles in the gastrointestinal tract.1 Pathophysiologic GI dysfunction after severe TBI occurs at a cellular level. TBI results in increased intestinal permeability from apoptosis of intestinal epithelial cells that contain large numbers of mitochondria, which disrupts gastrointestinal homeostasis.2 This enterocyte mitochondrial dysfunction disrupts GI enzymatic function.3 The parasympathetic input to the GI system, which is responsible for facilitating GI motility, comes from the neurologic input from the cranium and from the sacrum. The paraventricular nucleus of the hypothalamus, which is responsible for maintaining autonomic regulation, can be damaged in patients with severe TBI, which can further inhibit the physiologic function of the GI system. 
The use of powerful opioid narcotic analgesics such as fentanyl and morphine are common in patients with severe TBI, who also commonly have major orthopedic and visceral injuries that require surgery.4 The use of opioids that have a profound decrease in GI motility has been extensively studied in both human and animal models and is understood at a molecular level.5 Osteopathic manipulative treatment (OMT) has been proven effective in stimulating GI motility in patients who have undergone abdominal surgery and in whom postoperative ileus developed.6 
Mesenteric lift is an OMT technique designed to remove tension from the root of the mesentery of the posterior body wall, compress the bowel wall, and initiate peristalsis through a stretch reflex. We hypothesized that intubated patients with severe TBI who received mesenteric lift would be more likely to resume normal bowel function within 24 hours of receiving OMT than those who did not. 
Methods
This retrospective medical record review was deemed exempt by the Institutional Review Board, Office of Research and Grants at Arrowhead Regional Medical Center. Records of patients admitted to our institutions with severe TBI who required intubation and admission to the ICU between January 20, 2009, and November 8, 2016 were reviewed. 
Protocol
Patients were selected for this study if they had received a bowel regimen that consisted of scheduled daily doses of bisacodyl and docusate sodium, received nasogastric tube feeding within 24 hours of presentation, and received the same fluid management with a 0.9% saline solution and maintenance fluids based on the patient's body weight in kilograms. Patients were excluded if their records showed any blunt or penetrating trauma to the abdominal cavity, any injury to the spine or spinal cord, or any history of abdominal or pelvic surgery. We also excluded patients with known diabetes, because autonomic nerve function can be inhibited by diabetic autonomic neuropathy. The control group consisted of patients with TBI who were admitted to the ICU while intubated and who were unable to have a bowel movement within 48 hours of admission but who did not receive mesenteric lift. (Control group patients did not receive mesenteric lift because both allopathic and osteopathic neurosurgeons participated in the residency program in which this study occurred; during the days when allopathic neurosurgeons were on call, no OMT was performed.) Patients were intubated in the trauma unit before arriving in the ICU. The OMT technique was performed by attending osteopathic neurosurgeons (D.M.) and residents under direct supervision (J.A.D.B., J.O., S.K., and H.S.). The treatment and control groups received a full bowel regimen of medications to facilitate a bowel movement. 
Mesenteric Lift Technique
Patients were positioned supine in their beds. The physician stood on the right side of the patient and bent the patient's knees. The physician's hands were placed on the abdominal wall on either side of the cecum wall in the right lower quadrant with the fingers medial to the anterior superior iliac spine. A gentle scooping motion was performed with the fingers that started in the region of the cecum in the right lower quadrant, then moved superior to the transverse colon, and then moved to the right across the midline. The physician performed a lifting motion after pressing deeper into the abdomen. A deep technique was used to mobilize the abdominal viscera. The technique then followed the colonic wall down the right side, toward the sigmoid. 
Results
Seventy-nine patients (35 study, 44 control) met the inclusion criteria. Their ages ranged from 19 to 83 years (mean, 42 years), and the majority were men (men, 29 [66%]; women, 15 [34%]). The study group population ranged from age 17 to 69 years (mean, 39 years). There was also a slight male predominance (men, 24 [68%]; women, 11 [32%]). After receiving OMT, 27 of 35 patients (77%) had a bowel movement within 24 hours of completing treatment, compared with 16 of 44 (36%) control patients (P=.01). Patients who received mesenteric lift within the specified period in our study were 212% more likely to have a bowel movement compared with those who did not. 
Discussion
Neurogenic bowel is a common occurrence in patients with TBI, with reported rates ranging from 30% to 60%.7 In severe TBI, a sympathetic surge shunts blood away from the mesenteric vessels of the GI tract and into the muscles. This disrupts the normal balance and regulation of sympathetic and parasympathetic discharge from the hypothalamus and the fibers, which both enter and leave this autonomic center. The celiac, superior mesenteric, and inferior mesenteric ganglia are the primary autonomic ganglia in the enteric nervous system. The enteric nervous system contains more cell bodies than the spinal cord and is almost exclusively controlled by autonomic influences both sympathetic and parasympathetic.8 
The autonomic efferent motor neurons in the myenteric (Auerbach) and submucosal (Meissner) plexuses contain μ-, κ-, and δ-opioid receptors that are extremely sensitive to opioid agonists, which cause a decrease in motility, secretion, and sphincter function.9 ICU patients often receive medications that are necessary for their clinical management but which greatly affect the autonomic nervous system. This adverse effect is seen frequently with the use of vasopressors, which are often used in patients with TBI to maintain adequate systolic blood pressure, mean arterial pressure, and cerebral perfusion pressure. These medications also increase shunting of blood away from the mesenteric system and toward the muscles. Additionally, opiates play a significant role in reducing GI motility. These factors contribute to a decrease in GI motility that can interfere with fluid absorption and expel waste from the body. The inability to properly absorb fluids, nutrients, and medications due to decreased blood flow to the GI tract can be detrimental in patients with severe TBI. 
Although there are limited data documenting the efficacy of OMT in adult patients in the ICU, its use in a critical care setting is supported in the literature. Two studies,10,11 in particular, have shown significant improvements in GI function in preterm neonates in the ICU that have resulted in reduced length of stay, increased weight gain, and reduced medical costs. The mesenteric lift technique can function as both a direct and indirect technique. As a direct technique, it manually promotes persistalsis in the GI tract and can potentially relieve mechanical obstructions by softening and mobilizing stool. Indirectly, it can be a form of myofascial release, releasing visceral restrictions.11 
Limitations
Several limitations exist in this study that introduce potentially confounding variables. The retrospective nature inherently introduces a selection bias. Because of limitations with our institution's medical records system, it was difficult to analyze which patients in our treatment and control groups were receiving vasopressors and opiate drips and for what duration; these factors are confounding variables because they can play a role in the constipation rates in both patient groups. An additional limitation is that much of the medical history of the patients was unknown, as trauma patients often do not have any identifying information for several days. 
Conclusion
This increase in GI motility shown in our study resulting from mesenteric lift improves the absorption of nutrients, medications, and fluids, which can improve clinical outcomes. While this study focused on a very specialized patient population, we believe that OMT can be applied to a broader population to optimize the functioning of the GI system. 
Table.
Effect of Mesenteric Lift Technique on Gastrointestinal Motility in Intubated Trauma Patients
Patient group Bowel movement between 48 and 72 hours No bowel movement between 48 and 72 hours Total
Treated with mesenteric lift 27 8 35
Not treated with mesenteric lift 16 28 44
Totals 43 36 79
Table.
Effect of Mesenteric Lift Technique on Gastrointestinal Motility in Intubated Trauma Patients
Patient group Bowel movement between 48 and 72 hours No bowel movement between 48 and 72 hours Total
Treated with mesenteric lift 27 8 35
Not treated with mesenteric lift 16 28 44
Totals 43 36 79
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Author Contributions
All authors provided substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; all authors drafted the article or revised it critically for important intellectual content; all authors gave final approval of the version of the article to be published; and all authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. 
References
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Liu Y, Bao Z, Xu X, et al. Extracellular signal-regulated kinase/nuclear factor-erythroid2-like2/heme oxygenase-1 pathway-mediated mitophagy alleviated traumatic brain injury-induced intestinal mocusa damage and epithelial barrier dysfunction. J Neurotrauma. 2017;34(13):2119-2131. doi: 10.1089/neu.2016.4764 [CrossRef] [PubMed]
Zhu K-J, Huang H, Chu H, Yu H, Zhang SM. Alterations in enterocyte mitochondrial respiratory function and enzyme activities in gastrointestinal dysfunction following brain injury. World J Gastroenterol. 2014;20(28):9585-9591. doi: 10.3748/wjg.v20.i28.9585 [CrossRef] [PubMed]
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Müller-Lissner S, Bassotti G, Coffin B, et al Opioid-induced constipation and bowel dysfunction: a clinical guideline. Pain Med. 2017;18(10):1837-1863. doi: 10.1093/pm/pnw255. [PubMed]
Baltazar GA, Betler MP, Akella K, Khatri R, Asaro R, Chendrasekar A. Effect of osteopathic manipulative treatment on incidence of postoperative ileus and hospital length of stay in general surgical patients [published correction appears in J Am Osteopath Assoc. 2013 Apr;113(4):271]. J Am Osteopath Assoc. 2013;113(3):204-209.
Lim YH, Kim DH, Lee MY, Joo MC. Bowel dysfunction and colon transit time in brain-injured patients. Ann Rehabil Med. 2012;36(3):371-378. doi: 10.5535/arm.2012.36.3.371 [CrossRef] [PubMed]
Furness JB, Callaghan BP, Rivera LR, Cho HJ. The enteric nervous system and gastrointestinal innervation: integrated local and central control. Adv Exp Med Biol. 2014;817:39-71. doi: 10.1007/978-1-4939-0897-4_3 [CrossRef] [PubMed]
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Cerritelli F, Pizzolorusso G, Ciardelli F, et al. The effect of osteopathic manipulative treatment on length of stay in a population of preterm infants: a randomized controlled trial. BMC Pediatr. 2013;13:65. doi: 10.1186/1471-2431-13-65
Cerritelli F, Pizzolorusso G, Renzetti C, et al. A multicenter, randomized, controlled trial of osteopathic manipulative treatment on preterms. PLoS One. 2115;10(5):e0127370. doi: 10.1371/journal.pone.0127370 [CrossRef]
Table.
Effect of Mesenteric Lift Technique on Gastrointestinal Motility in Intubated Trauma Patients
Patient group Bowel movement between 48 and 72 hours No bowel movement between 48 and 72 hours Total
Treated with mesenteric lift 27 8 35
Not treated with mesenteric lift 16 28 44
Totals 43 36 79
Table.
Effect of Mesenteric Lift Technique on Gastrointestinal Motility in Intubated Trauma Patients
Patient group Bowel movement between 48 and 72 hours No bowel movement between 48 and 72 hours Total
Treated with mesenteric lift 27 8 35
Not treated with mesenteric lift 16 28 44
Totals 43 36 79
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