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 |
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
Questions to ask a patient presenting with recurrent vomiting
denotes symptoms for the possible diagnosis of an urgent or dangerous problem.
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
Mechanical obstruction |
Neuromuscular motility disorders (hints from the history: solids and liquids equally difficult, symptoms intermittent) |
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.
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.
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
Questions to ask a patient who reports difficulty swallowing
! denotes symptoms for the possible diagnosis of an urgent or dangerous problem.
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.
Questions to ask the patient presenting with diarrhoea
! denotes symptoms for the possible diagnosis of an urgent or dangerous problem.
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.
Constipation
It is important to determine what patients mean if they say they are constipated.
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.
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 (
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 Causes of acute gastrointestinal bleeding
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
Questions to ask a patient presenting with constipation
! denotes symptoms for the possible diagnosis of an urgent or dangerous problem.
Questions to ask the patient who presents with vomiting blood (haematemesis)
! denotes symptoms for the possible diagnosis of an urgent or dangerous problem. !
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
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
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
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
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
Questions to ask the patient presenting with jaundice
! denotes symptoms for the possible diagnosis of an urgent or dangerous problem. !
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