Pyloric Botox injections


Hailey Alfred
 

Hi all!,

I have a patient that I have now seen for 3 visits for c/o GI pain, bloating, nausea, and difficulty eating.  She is currently undergoing testing for the cause of dysfunction (urine analysis, SIBO breath test, CT scan, etc).  She has also been diagnosed with EoE which is not currently inflamed.  She is on a clear diet most days currently due to difficulty eating. When she does ingest solids she c/o pain under both rib cages (not simultaneously) that doubles her over. When she gets nauseous she does throw up and reports the foods are undigested even 15+ hours after eating to the point she can still recognize the exact medication capsules still. She also has POTS and ehlers-danlos syndrome. 

GL: backwards fold T-L junction level (I’m not the best with General listening)
LL: gallbladder and ducts towards oddi, pyloric sphincter, Cindy’s of stomach, manubrium deep and tubelike (I’m thinking esophagus). 

Nearly no stomach motility felt, restricted superior stomach glides. Slow gallbladder motility. 


She is able to eat “normally” for a day after treatment, then almost normally for about 1.5 weeks before sx return.

Hopefully that’s enough info for the big question….  She is undergoing a treatment for her EoE in a month… they have her scheduled to have pyloric Botox at the same time but she asked my opinion on if she should do the Botox component since it’s elective. Her MD told her it may help with the nausea, and throwing up… or it could make it worse.  She does not know what to do, and I don’t have enough experience to tell her yes or no. Any experience out there with the benefits/risks of this procedure? Her pyloric sphincter does rotate clockwise with light induction, it’s a little sluggish but I can’t tell if it’s because of spasm or hypomobility which definitely would bias Botox or no Botox. I think more of the issue is gastroparesis than the pyloric sphincter, 

Any advice greatly appreciated!
hailey Alfred, PT
VM 1-4


drmariotti@...
 

Hi Hailey;

Great question. This really shows the complexity of the digestive system, don't you think?  

BTW, a couple of responses have come in but I decided not to pass them along. Please remember everyone, this is a VM forum. I ask if you are going to present cases or respond to cases that you think within the paradigm of JP's work. 

This is a great question to stimulate some "VM thinking". Please understand, when I say VM I'm referencing all the work JP has spent the past 50 years developing. It really is quite the brilliant body of work. 

So, let's put on our VM hats and see how we might help Hailey  with this patient. 

I have some ideas but I would really like to see what you all come up with. 

Hints....think physiology, think anatomy!  Why is this patient's MD recommending botox of the pyloric sphincter? So, let's say she goes for it. What sort of complications might this cause? So, what's the function of the pyloric sphincter anyway? Does it act all alone or will interrupting its function have other complications? And what might those be? 

BTW, if you are going to respond please use Hailey's question as a template. She used her name at the end of her question and she even included the VM curriculum classes she has taken. Thank you Hailey! This is very helpful. 

Ron


Mindy Marantz
 

Hello,

Thank you Ron for clarifying your framework for response. I will refrain from discussing the very important relationship between hEDS, POTS, and Mast Cell Activation Syndrome (MCAS), and SIBO even though I strongly encourage my colleagues to read Amber Walker’s “The Trifecta Passport” that addresses these subjects. I will only add that if the patient’s mast cells are hypersensitized by an underlying viral or infectious load, our work will likely not hold. In fact, when my treatments do not hold, I return to exploring these things in their history as root causes. 

That said, what  comes to mind regarding hEDS Is that these patients tend to have ptosis globally throughout their viscera. Any and all efforts to improve motility will benefit them. Any and all efforts to improve their fluid system, be it lymph flow or vascular flow, will benefit them. They frequently have gastroparesis, improving blood flow to the organs will facilitate mobility. Prioritize treatment by following the listening, GL and LL as you’ve done!

In terms of utilizing Botox to disable the pylorus’s inhibitory affect of allowing in-adequately masticated food to pass at a low Ph into the duodenum, I would discourage that approach because it’s just masking symptoms of a larger root problem, again, like MCAS whereby underlying inflammation must be addressed.

The patient needs to carefully access their diet and medications and their environment for “triggers” and work in conjunction with manual work to down regulate their sympathetic nervous system, and then reaccess. It’s like having your finger caught in the door, and injecting Botox to reduce the pain rather than opening the door and addressing the root cause of the pain.

Another thought is if your first swing at treatment is not as effective as you’d hope, head downstream. Are the major pressure systems balanced?

Most importantly, in addition to treating motility for visceral ptosis, address the diaphragm due to the important structures running through it, including the vagus nerve, sympathetic chain, the esophagus, long thoracic duct, inf vena cava, as these  all will impact the digestive process if the diaphragm is restricted. 

These are just a few thoughts that I hope are helpful.

Best,
Mindy
VM 1-6, NM 1-5, +++

Mindy Marantz PT MS GCFP
Founder/Director
Healthwell Physical Therapy Group
1200 Gough Street
San Francisco, Ca 94109
www.healthwellpt.com


On Jul 22, 2021, at 8:28 AM, drmariotti via groups.io <drmariotti@...> wrote:

Hi Hailey;

Great question. This really shows the complexity of the digestive system, don't you think?  

BTW, a couple of responses have come in but I decided not to pass them along. Please remember everyone, this is a VM forum. I ask if you are going to present cases or respond to cases that you think within the paradigm of JP's work. 

This is a great question to stimulate some "VM thinking". Please understand, when I say VM I'm referencing all the work JP has spent the past 50 years developing. It really is quite the brilliant body of work. 

So, let's put on our VM hats and see how we might help Hailey  with this patient. 

I have some ideas but I would really like to see what you all come up with. 

Hints....think physiology, think anatomy!  Why is this patient's MD recommending botox of the pyloric sphincter? So, let's say she goes for it. What sort of complications might this cause? So, what's the function of the pyloric sphincter anyway? Does it act all alone or will interrupting its function have other complications? And what might those be? 

BTW, if you are going to respond please use Hailey's question as a template. She used her name at the end of her question and she even included the VM curriculum classes she has taken. Thank you Hailey! This is very helpful. 

Ron


Hailey Alfred
 

Hi,

Thank you Ron for helping to clarify the responses to my questions. 

To answer your questions... I think her MD wants to do the botox as a possible way to let stomach contents out through that opening instead of the esophageal sphincter when the stomach fills or pressure builds up; so the pyloric sphincter would be the "weakest link" and stomach contents will exit that direction (physics right :)).  This may help her EOE/GERD or vomiting, but is not going to fix the problem of gastroparesis which may then lead to a host of issues at the duodenum as Mindy also alluded to. Does this sound right?  

Mindy, I have not formally checked the pelvic floor organs as I have not felt a listening there yet. She has had a pelvic floor internal examination with a women's health PT who said muscle-wise her pelvic floor is fine. 

I will be taking VM5 in February of next year which will help with my techniques with blood flow correct? In the meantime, I will follow the listening (I take LT1 in October if I get off the waitlist), and see where it takes me, and focus on improvement in motility throughout the abdomen and pelvic floor.  She is not overly interested in the botox, so I now feel comfortable explaining these things to her so she can make a more educated decision for herself. 

Mindy, I am interested in that book. Does it just explain the trifecta, or does it also offer treatment solutions. Interestingly, she went to Germany for 2 months and did not have one adverse symptom while there.  We have been racking our brains to determine if there was a difference in anything obvious and there was not. Her MD thinks she felt great in Germany because it was right after an intense antiinflammatory IV treatment protocol she was on prior to leaving.

 I feel many of my patients could benefit from an assessment of diet, supplements, inflammation, etc, but do not know who to refer to for those principles that I am not trained in. Ron, I have your naturopathic approach book and see the herb/supplements section at each chapter, but do not know how to use that confidently enough  to give advice (ie how many doses, how often, for how long, with food/without food, etc). Do you know of a database alike to the IAHP that lists specialists in these areas? I am currently in Phoenix, AZ. 

Thank you all for your help!
I truly love this work and cannot wait to become a skilled practitioner in this field :)
-Hailey


Leía Ambra
 

I would discourage the use of Botox, because then, the sphincter will not be able to work at all, which will cause all kinds of problems down the road, like reflux etc, which can not be undone. I would really follow the GL, and use inhibition to see if you are on the right area in GL (like, the body will straighten and feels like your hand will be pushed off the head if your other hand inhibits in the correct GL area). If GL/LL takes you to one sphincter, I would make sure you look at ALL five sphincter, and start by addressing the 'driver' of the sphincters, ie the primary dysfunctional sphincter, and keep going, assessing the next primary dysfunctional sphincter, until they all work well (I have had the experience of, when I released the celiac sphincter, which was the primary dysfunctional one, the Sphincter of Oddi and all others improved incredibly).
Best wishes, definitely a complicated patient!

Leia Ambra

On Wed, Jul 21, 2021 at 2:16 PM Hailey Alfred <hailey@...> wrote:

Hi all!,

I have a patient that I have now seen for 3 visits for c/o GI pain, bloating, nausea, and difficulty eating.  She is currently undergoing testing for the cause of dysfunction (urine analysis, SIBO breath test, CT scan, etc).  She has also been diagnosed with EoE which is not currently inflamed.  She is on a clear diet most days currently due to difficulty eating. When she does ingest solids she c/o pain under both rib cages (not simultaneously) that doubles her over. When she gets nauseous she does throw up and reports the foods are undigested even 15+ hours after eating to the point she can still recognize the exact medication capsules still. She also has POTS and ehlers-danlos syndrome. 

GL: backwards fold T-L junction level (I’m not the best with General listening)
LL: gallbladder and ducts towards oddi, pyloric sphincter, Cindy’s of stomach, manubrium deep and tubelike (I’m thinking esophagus). 

Nearly no stomach motility felt, restricted superior stomach glides. Slow gallbladder motility. 


She is able to eat “normally” for a day after treatment, then almost normally for about 1.5 weeks before sx return.

Hopefully that’s enough info for the big question….  She is undergoing a treatment for her EoE in a month… they have her scheduled to have pyloric Botox at the same time but she asked my opinion on if she should do the Botox component since it’s elective. Her MD told her it may help with the nausea, and throwing up… or it could make it worse.  She does not know what to do, and I don’t have enough experience to tell her yes or no. Any experience out there with the benefits/risks of this procedure? Her pyloric sphincter does rotate clockwise with light induction, it’s a little sluggish but I can’t tell if it’s because of spasm or hypomobility which definitely would bias Botox or no Botox. I think more of the issue is gastroparesis than the pyloric sphincter, 

Any advice greatly appreciated!
hailey Alfred, PT
VM 1-4


Linda Fisher
 

Hi Mandy,

Thanks so much for your response. I  always learn so much from your responses.

Warm regards,

Linda S. Fisher RMT
http://www.iahp.com/Linda-Fisher




Renee Miller
 

Long time listener, first time caller, but I've been thinking about this since I read it the other day, so I decided to share my thoughts. Gulp...

When I get a GL that "backward folds," it makes me think parietal peritoneum, especially posterior parietal peritoneum. That along with the local listening to gb & ducts towards Oddi, it makes me think about where the duodenum passes out through the posterior parietal peritoneum and then back in again. Common bile duct and pancreas is retroperitoneal... And how about the phrenic nerve?

In my practice, I see a lot of dysfunction in this area with people with EDS and/or POTS, I think due to the common bile duct being such close neighbors with the portal vein/inf vena cava, abdominal aorta, and nerve plexuses.

And if Oddi is chronically dysfunctional or the common bile duct or nerve/vasculature is restricted in any way, I could see how motility of plyorus, stomach, pancreas and gb would also slow down.

I can see wanting relief asap, but to go through a treatment like botox could open up other possible issues and maybe not give the patient relief if it's not the root of the symptoms.

I don't know how helpful that was, but please give us an update on what happens!

Renee Miller, PT, DPT
VM 1-5, Listening 1&2, CST 1


From: Visceral-Manipulation-Forum@groups.io <Visceral-Manipulation-Forum@groups.io> on behalf of Hailey Alfred <hailey@...>
Sent: Wednesday, July 21, 2021 4:13:36 PM
To: Visceral-Manipulation-Forum@groups.io <Visceral-Manipulation-Forum@groups.io>
Subject: [vmforum] Pyloric Botox injections
 

Hi all!,

I have a patient that I have now seen for 3 visits for c/o GI pain, bloating, nausea, and difficulty eating.  She is currently undergoing testing for the cause of dysfunction (urine analysis, SIBO breath test, CT scan, etc).  She has also been diagnosed with EoE which is not currently inflamed.  She is on a clear diet most days currently due to difficulty eating. When she does ingest solids she c/o pain under both rib cages (not simultaneously) that doubles her over. When she gets nauseous she does throw up and reports the foods are undigested even 15+ hours after eating to the point she can still recognize the exact medication capsules still. She also has POTS and ehlers-danlos syndrome. 

GL: backwards fold T-L junction level (I’m not the best with General listening)
LL: gallbladder and ducts towards oddi, pyloric sphincter, Cindy’s of stomach, manubrium deep and tubelike (I’m thinking esophagus). 

Nearly no stomach motility felt, restricted superior stomach glides. Slow gallbladder motility. 


She is able to eat “normally” for a day after treatment, then almost normally for about 1.5 weeks before sx return.

Hopefully that’s enough info for the big question….  She is undergoing a treatment for her EoE in a month… they have her scheduled to have pyloric Botox at the same time but she asked my opinion on if she should do the Botox component since it’s elective. Her MD told her it may help with the nausea, and throwing up… or it could make it worse.  She does not know what to do, and I don’t have enough experience to tell her yes or no. Any experience out there with the benefits/risks of this procedure? Her pyloric sphincter does rotate clockwise with light induction, it’s a little sluggish but I can’t tell if it’s because of spasm or hypomobility which definitely would bias Botox or no Botox. I think more of the issue is gastroparesis than the pyloric sphincter, 

Any advice greatly appreciated!
hailey Alfred, PT
VM 1-4