The gastrointestinal system

Table 6.1)



Abdominal pain


There are many causes of abdominal pain, and careful history taking will often lead to the correct diagnosis. The following should be considered.


TABLE 6.1 Gastrointestinal history







Major symptoms

Abdominal pain

Appetite and/or weight change

Postprandial fullness or early satiation, or both

Nausea and/or vomiting

Heartburn and/or acid regurgitation

Waterbrash

Dysphagia

Disturbed defecation (diarrhoea, constipation, faecal incontinence)

Bloating or visible distension, or both

Bleeding (haematemesis, melaena, rectal bleeding)

Jaundice

Dark urine, pale stools

Pruritus

Lethargy

Fever


Frequency and duration


Try to determine whether the pain is acute or chronic, when it began and how often it occurs.



Site and radiation


The site of pain is important. Ask the patient to point to the area affected by pain and to the point of maximum intensity. Parietal peritoneal inflammation that causes pain usually does so in a localised area. Ask about radiation of pain. Pain often radiates through to the back with pancreatic disease or a penetrating peptic ulcer. It may radiate to the shoulder with diaphragmatic irritation or to the neck with oesophageal reflux.



Character and pattern


The pain may be colicky (coming and going in waves and related to peristaltic movements) or steady. Colicky pain comes from obstruction of the bowel or the ureters. If the pain is chronic, ask about the daily pattern of pain.



Aggravating and relieving factors


Pain due to peptic ulceration may or may not be related to meals. Eating may precipitate ischaemic pain in the gut. Antacids or vomiting may relieve peptic ulcer pain or that of gastro-oesophageal reflux. Defaecation or passage of flatus may relieve the pain of colonic disease temporarily. Patients who get some relief by rolling around vigorously are more likely to have a colicky pain, while those who lie perfectly still are more likely to have peritonitis.



Patterns of pain



Peptic ulcer disease


This is classically a dull or burning pain in the epigastrium that is relieved to a degree by food or antacids. It is typically episodic and may occur at night, waking the patient from sleep. This combination of symptoms is suggestive of the diagnosis. The pain is often unrelated to meals, despite classical teaching to the contrary. It is not possible to distinguish duodenal ulceration from gastric ulceration clinically.



Pancreatic pain


This is a steady epigastric pain that may be partly relieved by sitting up and leaning forwards. There is often radiation of the pain to the back, and vomiting is common.



Biliary pain


Although usually called ‘biliary colic’, this pain is rarely colicky. With cystic duct obstruction there is often epigastric pain. It is usually a severe, constant pain that can last for hours. There may be a history of episodes of similar pain in the past. If cholecystitis develops, the pain typically shifts to the right upper quadrant and becomes more severe.



Renal colic


This is a colicky pain superimposed on a background of constant pain in the renal angle, often with radiation towards the groin. It can be very severe indeed.



Bowel obstruction


This is colicky pain. Periumbilical pain suggests a small bowel origin but colonic pain can occur anywhere in the abdomen. Small bowel obstruction tends to cause more frequent colicky pain (with a cycle every 2–3 minutes) than large bowel obstruction (every 10–15 minutes). Obstruction is often associated with vomiting, constipation and abdominal distension.



Appetite and weight change


Loss of appetite (anorexia) and weight loss are important gastrointestinal symptoms. The presence of both anorexia and weight loss should make one suspicious of an underlying malignancy, but may also occur with depression and in other diseases. The combination of weight loss with an increased appetite suggests malabsorption of nutrients or a hypermetabolic state (e.g. thyrotoxicosis). It is important to document when the symptoms began and how much weight loss has occurred over this period. Liver disease can sometimes cause disturbance of taste. This may cause smokers with acute hepatitis and jaundice to give up smoking.



Early satiation and postprandial fullness


Inability to finish a normal meal (early satiation) may be a symptom of gastric diseases, including gastric cancer and peptic ulcer. A feeling of inappropriate fullness after eating can also be a symptom of functional (unexplained) gastrointestinal disease.



Nausea and vomiting


Nausea is the sensation of wanting to vomit. Heaving and retching may occur but there is no expulsion of gastric contents. There are many possible causes for these complaints. Gastrointestinal tract infections (e.g. from food poisoning by Staphylococcus aureus) or small bowel obstruction can cause acute symptoms. In patients with chronic symptoms, pregnancy and drugs (e.g. digoxin, opiates, dopamine agonists, chemotherapy) should always be ruled out. In the gastrointestinal tract, peptic ulcer disease with gastric outlet obstruction, motor disorders (e.g. gastroparesis from diabetes mellitus, or after gastric surgery), acute hepatobiliary disease and alcoholism are important causes. Finally, psychogenic vomiting, eating disorders (e.g. bulimia) and, rarely, increased intracranial pressure should be considered in patients with chronic unexplained nausea and vomiting.


The timing of the vomiting can be helpful; vomiting delayed more than 1 hour after the meal is typical of gastric outlet obstruction or gastroparesis, while early morning vomiting before eating is characteristic of pregnancy, alcoholism and raised intracranial pressure. Also ask about the contents of the vomitus (e.g. bile indicates an open connection between the duodenum and stomach, old food suggests gastric outlet obstruction, while blood suggests ulceration).



Heartburn and acid regurgitation


Heartburn refers to the presence of a burning pain or discomfort in the retrosternal area. Typically, this sensation travels up towards the throat and occurs after meals or is aggravated by bending, stooping or lying supine. Antacids usually relieve the pain, at least transiently. This symptom is due to regurgitation of stomach contents into the oesophagus. Usually these contents are acidic, although occasionally alkaline reflux can induce similar problems. Associated with gastro-oesophageal reflux may be acid regurgitation, in which the patient experiences a sour or bitter-tasting fluid coming up into the mouth. This symptom strongly suggests that reflux is occurring. Some patients complain of a cough that troubles them when they lie down. In patients with gastro



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Questions box 6.1


Questions to ask a patient presenting with recurrent vomiting


denotes symptoms for the possible diagnosis of an urgent or dangerous problem.


1. How long have you been having attacks of vomiting (distinguish acute from chronic)?

2. Does the vomiting occur with nausea preceding it, or does it occur without any warning?

3. Is the vomiting usually immediately after a meal or hours after a meal?

4. Do you have vomiting early in the morning or late in the evening?

5. What does the vomit look like? Is it bloodstained, bile-stained or faeculent?—Gastro-intestinal bleeding or bowel obstruction

6. Do you have specific vomiting episodes followed by feeling completely well for long periods before the vomiting episode occurs again?—Cyclical vomiting syndrome

7. Is there any abdominal pain associated with the vomiting?

8. Have you been losing weight?

9. What medications are you taking?

10. Do you have worsening headaches?—Neurological symptoms suggest a central cause

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oesophageal reflux disease, the lower oesophageal sphincter muscle relaxes inappropriately. Reflux symptoms may be aggravated by alcohol, chocolate, caffeine, a fatty meal, theophylline, calcium channel blockers and anticholinergic drugs, as these lower the oesophageal sphincter pressure.


Waterbrash refers to excessive secretion of saliva into the mouth and should not be confused with regurgitation; it may occur, uncommonly, in patients with peptic ulcer disease or oesophagitis.



Dysphagia


Dysphagia is difficulty in swallowing. Such difficulty may occur with solids or liquids. The causes of dysphagia are listed in Table 6.2. If a patient complains of difficulty swallowing, it is important to differentiate painful swallowing from actual difficulty.1 Painful swallowing is termed odynophagia and occurs with any severe inflammatory process involving the oesophagus. Causes include infectious oesophagitis (e.g. Candida, herpes simplex), peptic ulceration of the


TABLE 6.2 Causes of dysphagia









Mechanical obstruction
Intrinsic (within oesophagus)

Reflux oesophagitis with stricture formation

Carcinoma of oesophagus or gastric cardia

Pharyngeal or oesophageal web

Pharyngeal pouch

Schatzki (lower oesophageal) ring

Foreign body

Extrinsic (outside oesophagus)

Goitre with retrosternal extension

Mediastinal tumours, bronchial carcinoma, vascular compression (rare)

Neuromuscular motility disorders (hints from the history: solids and liquids equally difficult, symptoms intermittent)

Achalasia

Diffuse oesophageal spasm

Scleroderma

Pharyngeal dysphagia (hints: aspiration, fluid regurgitation into the nose)

Cricopharyngeal dysfunction—Zenker’s diverticulum

Neurological diseases: bulbar or pseudobulbar palsy, myasthenia gravis, polymyositis, myotonic dystrophy


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Questions box 6.2


Questions to ask the patient with acid reflux or suspected gastro-oesophageal reflux disease (GORD)


! denotes symptoms for the possible diagnosis of an urgent or dangerous problem.


1. Do you have heartburn (a burning pain under the sternum radiating up towards the throat)? How often does this occur?—More than once a week suggests GORD

2. Does your heartburn occur after meals or when you lean forward or lie flat in bed (typical of acid reflux)?

3. Does the pain radiate across the chest down the left arm or into the jaw?—Suggests myocardial ischaemia

4. Is the pain relieved by antacids or over-the-counter acid-suppressing medicines?

5. Do you experience suddenly feeling bitter tasting fluid in the mouth?—Acid regurgitation

6. Have you experienced the sudden appearance of a salty tasting or tasteless fluid in the mouth?—Waterbrash

7. Have you had trouble swallowing?—Dysphagia (see Questions box 6.3)

8. Have you been troubled by a cough when you lie down?

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oesophagus, caustic damage to the oesophagus or oesophageal perforation.


If the patient complains of difficulty initiating swallowing, fluid regurgitating into the nose or choking on trying to swallow, this suggests that the cause of the dysphagia is in the pharynx (pharyngeal dysphagia). Causes of pharyngeal dysphagia can include neurological disease (e.g. motor neurone disease, resulting in bulbar or pseudobulbar palsy).


If the patient complains of food sticking in the oesophagus, it is important to consider a number of anatomical causes of oesophageal blockage.1 Ask the patient to point to the site where the solids stick. If there is a mechanical obstruction at the lower end of the oesophagus, most often the patient will localise the dysphagia to the lower retrosternal area. However, obstruction higher in the oesophagus may be felt anywhere in the retrosternal area. If heartburn is also present, for example, this suggests that gastro-oesophageal reflux with or without stricture formation may be the cause of the dysphagia. The actual course of the dysphagia is also a very important part of the history to obtain. If the patient states that the dysphagia is intermittent or is present only with the first few swallows of food, this suggests either a lower oesophageal ring or oesophageal spasm. However, if the patient complains of progressive difficulty swallowing, this suggests a stricture, carcinoma or achalasia. If the patient states that both solids and liquids stick, then a motor disorder of the oesophagus is more likely, such as achalasia or diffuse oesophageal spasm.



Diarrhoea


The symptom diarrhoea can be defined in a number of different ways. Patients may complain of frequent stools (more than three per day being abnormal) or they may complain of a change in the consistency of the stools, which have become loose or watery. There are a large number of possible causes of diarrhoea.


Some patients pass small amounts of formed stool more than three times a day because of an increased desire to defecate. The stools are not loose and stool volume is not increased. This is not true diarrhoea. It can occur because of local rectal pathology, incomplete rectal emptying, or because of a psychological disturbance that leads



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Questions box 6.3


Questions to ask a patient who reports difficulty swallowing


! denotes symptoms for the possible diagnosis of an urgent or dangerous problem.


1. Do you have trouble swallowing solids, liquid or both?—Solids and liquids suggests a motor problem, e.g. achalasia

2. Where does the hold-up occur (please point to the area)?—Oesophageal carcinoma

3. Is the trouble swallowing intermittent or persistent?—Intermittent suggests eosinophilic oesophagitis

4. Has the problem been getting progressively worse?

5. Do you cough or choke on starting to swallow (oropharyngeal dysphagia)?

6. Is it painful to swallow (odynophagia)?

7. Do you have any heartburn or acid regurgitation?

8. Have you been losing weight?

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to an increased interest in defaecation.


When a history of diarrhoea is obtained, it is also important to determine if this has occurred acutely or whether it is a chronic problem. Acute diarrhoea is more likely to be infectious in nature, while chronic diarrhoea has a large number of causes.


Clinically, diarrhoea can be divided into a number of different groups based on the likely disturbance of physiology.2


1. Secretory diarrhoea is likely if the diarrhoea is of high volume (commonly more than 1 litre per day) and persists when the patient fasts; there is no pus or blood, and the stools are not excessively fatty. Secretory diarrhoea occurs when net secretion in the colon or small bowel exceeds absorption; some of the causes include infections (e.g. E. coli, Staphylococcus aureus, Vibrio cholerae), hormonal conditions (e.g. vasoactive intestinal polypeptide-secreting tumour, Zollinger-Ellisona syndrome, carcinoid syndrome) and villous adenoma.

2. Osmotic diarrhoea is characterised by its

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Questions box 6.4


Questions to ask the patient presenting with diarrhoea


! denotes symptoms for the possible diagnosis of an urgent or dangerous problem.


    1. How many stools a day do you pass now normally?

    2. What do the stools look like (stool form e.g. loose and watery)?

    3. Do you have to race to the bathroom to have a bowel movement?—Urgency in colonic disease

    4. Have you been woken from sleep during the night by diarrhoea?—Organic cause more likely

    5. Have you seen any bright-red blood in the stools or mucus or pus?—Suggests colonic disease

    6. Are you passing large volumes of stool every day?—Suggests small bowel disease

    7. Are your stools pale, greasy, smelly and difficult to flush away (steatorrhoea)? Have you seen oil droplets in the stool?—Pancreatic disease

    8. Have you had problems with leakage of stool (faecal incontinence)?

    9. Have you lost weight?—e.g. cancer, malabsorption

    10. Have you had any abdominal pain or vomiting?

    11. Have you had treatment with antibiotics recently?

    12. Have you had any recent travel? Where to?

    13. Have you a personal history of inflammatory bowel disease or prior gastrointestinal surgery?

    14. Have you any history in the family of coeliac disease or inflammatory bowel disease?

    15. Have you had any problems with arthritis?—Inflammatory bowel disease, Whipple’s disease

    16. Have you had recent fever, rigors, or chills (e.g. infection, lymphoma)? Have you had frequent infections?—Immunoglobulin deficiency

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disappearance with fasting and by large-volume stools related to the ingestion of food. Osmotic diarrhoea occurs due to excessive solute drag; causes include lactose intolerance (disaccharidase deficiency), magnesium antacids or gastric surgery.


3. Abnormal intestinal motility (e.g. thyrotoxicosis, the irritable bowel syndrome) can also cause diarrhoea.

4. Exudative diarrhoea occurs when there is inflammation in the colon. Typically the stools are of small volume but frequent, and there may be associated blood or mucus (e.g. inflammatory bowel disease, colon cancer).

5. Malabsorption of nutrients can result in steatorrhoea. Here the stools are fatty, pale coloured, extremely smelly, float in the toilet bowel and are difficult to flush away. Steatorrhoea is defined as the presence of more than 7 g of fat in a 24-hour stool collection. There are many causes of steatorrhoea (page 190).


Constipation


It is important to determine what patients mean if they say they are constipated.3 Constipation is a common symptom and can refer to the passage of infrequent stools (fewer than three times per week), hard stools or stools that are difficult to evacuate. This symptom may occur acutely or may be a chronic problem. In many patients, chronic constipation arises because of habitual neglect of the impulse to defecate, leading to the accumulation of large, dry faecal masses. With constant rectal distension from faeces, the patient may grow less aware of rectal fullness, leading to chronic constipation. Constipation may arise from ingestion of drugs (e.g. codeine, antidepressants and aluminium or calcium antacids), and with various metabolic or endocrine diseases (e.g. hypothyroidism, hypercalcaemia, diabetes mellitus, phaeochromocytoma, porphyria, hypokalaemia) and neurological disorders (e.g. aganglionosis, Hirschsprung’sb disease, autonomic neuropathy, spinal cord injury, multiple sclerosis). Constipation can also arise after partial colonic obstruction from carcinoma; it is, therefore, very important to determine whether there has been a recent change in bowel habit, as this may indicate development of a malignancy. Patients with very severe constipation in the absence of structural disease may be found on a transit study to have slow colonic transit; such slow-transit constipation is most common in young women.


Constipation is common in the later stages of pregnancy.


Difficulty with evacuation of faeces may occur with disorders of the pelvic floor muscles or nerves, or anorectal disease (e.g. fissure, or stricture). Patients with this problem may complain of straining, a feeling of anal blockage or even the need to self-digitate to perform manual evacuation of faeces.


A chronic but erratic disturbance in defaecation (typically alternating constipation and diarrhoea) associated with abdominal pain, in the absence of any structural or biochemical abnormality, is very common; such patients are classified as having the irritable bowel syndrome.4 Patients who report abdominal pain plus two or more of the following symptoms—abdominal pain relieved by defaecation, looser or more frequent stools with the onset of abdominal pain, passage of mucus per rectum, a feeling of incomplete emptying of the rectum following defaecation and visible abdominal distension—are more likely to have the irritable bowel syndrome than organic disease.



Mucus


The passage of mucus (white slime) may occur because of a solitary rectal ulcer, fistula or villous adenoma, or in the irritable bowel syndrome.



Bleeding


Patients may present with the problem of haematemesis (vomiting blood), melaena (passage of jet-black stools) or haematochezia (passage of bright-red blood per rectum). Sometimes patients may present because routine testing for occult blood in the stools is positive (page 183). It is important to ensure that if vomiting of blood is reported, this is not the result of bleeding from a tooth socket or the nose, or coughing up of blood.


Haematemesis indicates that the site of the bleeding is proximal to or at the duodenum. Ask about symptoms of peptic ulceration; haematemesis is commonly due to bleeding chronic peptic ulceration, particularly from a duodenal ulcer. Acute peptic ulcers often bleed without abdominal pain. A Mallory-Weiss tear usually occurs with repeated vomiting; typically the patient reports first the vomiting of clear gastric contents and then the vomiting of blood. Less-common causes of upper gastrointestinal bleeding are presented in Table 6.3.


TABLE 6.3 Causes of acute gastrointestinal bleeding











Upper gastrointestinal tract
More common
    1. Chronic peptic ulcer: duodenal ulcer, gastric ulcer

    2. Acute peptic ulcer (erosions)
Less common
3. Mallory-Weiss* syndrome (tear at the gastro-oesophageal junction)

4. Oesophageal and/or gastric varices

5. Erosive or ulcerative oesophagitis

6. Gastric carcinoma, polyp, other tumours

7. Dieulafoy’s† ulcer (single defect that involves an ectatic submucosal artery)

8. Watermelon stomach (antral vascular ectasias)

9. Aortoenteric fistula (usually aortoduodenal and after aortic surgery)

10. Vascular anomalies—angiodysplasia, arteriovenous malformations, blue rubber bleb naevus syndrome, hereditary haemorrhagic telangiectasia, CRST syndrome

11. Pseudoxanthoma elasticum, Ehlers-Danlos‡ syndrome

12. Amyloidosis

13. Vasculitis

14. Ménétrier’s§ disease

15. Bleeding diathesis

16. Pseudohaematemesis (nasopharyngeal origin)
Lower gastrointestinal tract
More common
    1. Angiodysplasia

    2. Diverticular disease

    3. Colonic carcinoma or polyp

    4. Haemorrhoids or anal fissure
Less common
5. Massive upper gastrointestinal bleeding

6. Inflammatory bowel disease

7. Ischaemic colitis

8. Meckel’s# diverticulum

9. Small bowel disease, e.g. tumour, diverticula, intussusception

10. Haemobilia (bleeding from the gallbladder)

11. Solitary colonic ulcer

CRST = calcinosis, Raynaud’s phenomenon, sclerodactyly and telangiectasia.


* George Kenneth Mallory (b. 1900), professor of pathology, Boston, and Soma Weiss (1898–1942), professor of medicine, Boston City Hospital described this syndrome in 1929.


† Georges Dieulafoy (1839–1911), Paris physician.


‡ Edvard Ehlers (1863–1937), German dermatologist, described the syndrome in 1901, and Henri Alexandre Danlos (1844–1912), French dermatologist, described the syndrome in 1908.


§ Pierre Ménétrier (1859–1935), French physician.


# Johann Friedrich Meckel the younger (1781–1833), Professor of Surgery and Anatomy at Halle. His father and grandfather were also professors of anatomy.


Haemorrhoids and local anorectal diseases such as fissures will commonly present with passing small amounts of bright-red blood per rectum. The blood is normally not mixed in the stools but is on the toilet paper, on top of the stools or in the toilet bowl. Melaena usually results from bleeding



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Questions box 6.5


Questions to ask a patient presenting with constipation


! denotes symptoms for the possible diagnosis of an urgent or dangerous problem.


1. How often do you have a bowel movement?

2. Are your stools hard or difficult to pass?

3. What do the stools look like (stool form e.g. small pellets)?

4. Do you strain excessively on passing stool?

5. Do you feel there may be a blockage at the anus area when you try to pass stool?

6. Do you ever press your finger in around the anus (or vagina) to help stool pass?

7. Has your bowel habit changed recently?

8. Any recent change in your medications?

9. Any blood in the stools?

10. Any abdominal pain?

11. Recent weight loss?

12. Do you ever have diarrhoea?

13. Do you have a history of colon polyps or cancer? Any family history of colon cancer?

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Questions box 6.6


Questions to ask the patient who presents with vomiting blood (haematemesis)


! denotes symptoms for the possible diagnosis of an urgent or dangerous problem. !


1. Was there fresh blood in the vomitus? Or was the vomitus coffee-grain stained?

2. Have you passed any black stools or blood in the stools?

3. Before any blood was seen in the vomitus, did you experience intense retching or vomiting?—Mallory-Weiss tear

4. Have you been taking aspirin, non-steroidal anti-inflammatory drugs or steroids?

5. Do you drink alcohol?

6. Have you ever had a peptic ulcer?

7. Have you lost weight?

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from the upper gastrointestinal tract, although right-sided colonic and small bowel lesions can occasionally be responsible. Massive rectal bleeding can occur from the distal colon or rectum, or from a major bleeding site higher in the gastrointestinal tract. With substantial lower gastrointestinal tract bleeding, it is important to consider the presence of angiodysplasia or diverticular disease (where bleeding more often occurs from the right rather than the left colon, even though diverticula are more common in the left colon). Less-common causes of lower gastrointestinal bleeding are presented in Table 6.3.


Spontaneous bleeding into the skin, or from the nose or mouth, can be a problem for patients with coagulopathy resulting from liver disease.



Jaundice


Usually the relatives notice a yellow discoloration of the sclerae or skin before the patient does. Jaundice is due to the presence of excess bilirubin being deposited in the sclerae and skin. The causes of jaundice are described on page 185. If there is jaundice, ask about the colour of the urine and stools; pale stools and dark urine occur with obstructive or cholestatic jaundice because urobilinogen is unable to reach the intestine. Also ask about abdominal pain; gallstones, for example, can cause biliary pain and jaundice.5



Pruritus


This symptom means itching of the skin, and may be either generalised or localised. Cholestatic liver disease can cause pruritus which tends to be worse over the extremities. Other causes of pruritus are discussed on page 445.



Abdominal bloating and swelling


A feeling of swelling (bloating) may be a result of excess gas or a hypersensitive intestinal tract (as occurs in the irritable bowel syndrome). Persistent swelling can be due to ascitic fluid accumulation; this is discussed on page 175. It may be associated with ankle oedema.



Lethargy


Tiredness and easy fatiguability are common symptoms for patients with acute or chronic liver disease, but the mechanism is not known. This can also occur because of anaemia due to gastrointestinal or chronic inflammatory disease. Lethargy is also very common in the general population and is not a specific symptom.




Treatment


The treatment history is very important. Traditional non-steroidal anti-inflammatory drugs (NSAIDs), including aspirin, can induce bleeding from acute or chronic damage to the gastrointestinal tract. As described above, many drugs can result in disturbed defaecation. A large number of drugs are also known to affect the liver. For example, acute hepatitis can occur with halothane, phenytoin or chlorothiazide. Cholestasis may occur from a



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Questions box 6.7


Questions to ask the patient presenting with jaundice


! denotes symptoms for the possible diagnosis of an urgent or dangerous problem. !


1. Is your urine dark? Are your stools pale?—Obstructive jaundice

2. Do you have any skin itching (pruritus)?

3. Have you had any fever?

4. Have you had a change in your appetite or weight?—Malignancy

5. Have you had any abdominal pain or change in bowel habit?

6. Have you had any vomiting of blood or passage of dark stools?

7. Do you drink alcohol? How much? How long? (CAGE questions, page 7)

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Mar 25, 2017 | Posted by in PHYSIOLOGY | Comments Off on The gastrointestinal system

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