Gastric Reflux / Heartburn

Gastric reflux is the regurgitation of the contents of the stomach back up into the oesophagus. All adults suffer with reflux to a degree but problems occur when the regurgitation becomes chronic and the oesophageal mucosa becomes inflamed. Normal physiology is for food to pass down through the oespohagus which punctures the diaphragm via the oesophageal aperture and enters the stomach. Pressure in the stomach exceeds pressure in the oesophagus so regurgitation would occur naturally were it not for the high pressure zone (HPZ) at the lower end of the oesophagus created by a lower eosophageal sphincter and contraction of the diaphragmatic crura.
The HPZ acts as a sphincter between the lower end of the oesophagus and the stomach. It is surrounded by the diaphragm muscle which helps to create this functional sphincter.

Osteopathic treatment of the gastric reflux must include the treatment of the diaphragm due to its close relationship with the oesophagus. There are local osteopathic techniques designed to stretch the diaphragm such as clasping the muscle underneath the costal margin and splaying the ribs. However, local muscular work to the diaphragm alone in an attempt to reduce symptoms will bear little success without observing global posture and tissue status throughout the body.

A comprehensive observation of the spinal curves is vital, with emphasis on thoraco-lumber junction and upper 2-3 lumber vertebra to which the diaphragmatic crura attach. Any restriction in movement of these vertebrae may be reflected in the crura. Since the body of the diaphragm can function independently of the crura dysfunction of the diaphragm is more perceptible in relation to its oesophageal relationship at the crura.

Quality of movement of the ribs especially the 11th and12th rib which is used by the diaphragm as a pivot on which to move provides information. The operator should apply gentle pressure to the lower ribs in order to see whether they are restricted in movement and if so in which direction. With the patient lying supine feel to see whether the 12th rib is raised off the table or not.

The xiphoid process is the diaphragm's anterior attachment. Any restriction in the function of the sternum may affect the diaphragm. Take for example poor abdominal tone resulting in the abdominal muscles dragging the sternum inferiorly and anteriorly further altering the diaphragm-rib cage relationship.

An osteopathic approach would be incomplete without examination of the cervical spine. The vagus nerve, which sits beneath the cranial base has the function of affecting gastric emptying time and acid secretion. Any irritation of the phrenic nerve at the level of C3, C4 and C5 could affect the function of the diaphragm which it innervates and receives sensory input.