This post was written by H&W instructor Brandi Kirk, PT, BCB-PMD. Brandi teaches Pelvic Floor Level One and Pelvic Floor Level 2A. You can catch Brandi teaching PF2A in Maywood, IL later this month!
Recently, I was lucky enough to attend a 3-day frozen cadaver (no formaldehyde) dissection course that sparked an inquiry in my ever-inquisitive mind. While we were working on our cadaver, the coroner who was working on the other side of the complex invited us over. She wanted to show us what Crohn’s disease looks like. She had small intestines on the table and they were dissected in order to show the inside lining. The terminal ileum, where the Crohn’s disease was located, had patches of red inflamed tissue in it. The coroner proceeded to say that there was a significant amount of adhesions along the cecum, around the ileocecal valve and into the terminal ileum stemming from a prior appendectomy. Of course my mind cannot just let this information go by without some analysis…. could the appendectomy have contributed to the development of Crohn’s disease?
Travel along this thought process with me for a moment. The field of science has, to date, not found the actual cause of Crohn’s disease. With the new information I gained at my dissection course, I began to formulate a theory. My theory? Maybe the adhesions and scar tissue created by the appendectomy began to cause issues in the terminal ileum, ileocecal valve and cecum. One issue could be a decreased flow in undigested or digested food particles/chyme that causes stagnation in the terminal ileum, and over time irritation and then an inflammation of the inner mucosa. The second issue could be that the adhesions could additionally cause a decrease in circulation and lymphatic flow in the area, which also could cause an inflammatory condition.
Evidently, I’m not the only one with an inquisitive mind in the medical community! When I got home from the course, I did a search on “appendectomy and Crohn’s disease.” There is actually research that has already been completed on the topic. Some of my findings were: Appendix surgery cause Crohn’s disease? This article discusses the January 2003 issue of Journal Gastroenterology where it was found that people who had their appendix removed were 47% more likely to develop Crohn’s disease than those who did not have surgery. Badgut.org: “ IBD and Appendectomy” This article discusses the appendix having an influence over the immune system and thus appendicitis increasing the risks of Crohn’s disease. IBD and Your Appendix: This article discusses two studies on this topic. The first one showed an increase risk of Crohn’s disease within the first 20 years after an appendectomy and that women were at a higher risk than men. Unfortunately, the article did not share why the women were at higher risk than men. The second study showed a hypothesis that the original attack of appendicitis may actually be the first flare of Crohn’s disease. Potentially the patient always had Crohn’s, which went undiagnosed until the disease progressed enough. It was stated that more research is definitely needed on this correlation.
So what does this mean for practicing therapists, who are treating patients who are suffering from Crohn’s disease? If the patient has had an appendectomy, we should start there. Use all of your manual therapy skills such as visceral manipulation, myofascial release, scar massage and connective tissue manipulation in that area. In my clinical experience, which is correlated to research findings, the pelvic musculature in patients with Crohn’s disease tends to be hypertonic. These muscles need to be treated, but only after you address all of the abdominal restrictions. Through my dissection course, I was able to expand my vision about how connected the human body is. I’m afraid that as “pelvic therapists,” we tend to get tunnel-vision and we tend to blame those poor little pelvic muscles that are usually just doing their job. Yes, in the patient with Crohn’s disease they will be hypertonic, but why? They are just trying to guard and protect! They will still have to be released, but maybe not as the first step in your treatment plan. Once you release some of the fascial restrictions and improve the movement of the intestines and improve the circulation and lymphatic flow, then the pelvic muscles will not have a reason to become hypertonic again after you release them.
So let’s try to keep in mind the correlation between appendectomies and Crohn’s disease and treat those fascial restrictions first before you treat the compensatory pelvic muscles.