Gastroenterology

Approach to the patient

Gastrointestinal diagnosis relies heavily on a careful and thorough history. A detailed description of the symptoms and ancillary data, such as exposure to contaminated food or water, previous episodes of illness, consumption of potentially toxic drugs, heritable illness, etc., is critically important.

KEY POINT

• Always introduce yourself and obtain verbal consent from the patient before proceeding with a detailed history and examination.

Presenting complaint

History taking should always start with an open question; asking the patient to 'describe in their own words what the trouble is' is helpful. If the answer is vague or non specific, more structured questions can then be asked. This is important for two reasons:

1 First, some symptoms, such as heartburn or dysphagia are so characteristically associated with certain conditions that the symptom naturally leads to the appropriate diagnostic hypothesis.

2 Second, where there may be a constellation of symptoms that need to be managed, knowing the patient ' s priorities guides the appropriate treatment strategy.

Gastrointestinal symptoms are often non-specific. For example, abdominal pain may indicate life-threatening acute pancreatitis or may be a feature of irritable bowel syndrome, which usually runs a benign course. Many serious diseases are asymptomatic until the late stages, and may only manifest with mild, vague symptoms such as malaise and fatigue. Be vigilant for changes-for example a change in bowel habit, change in food tolerance, change in energy levels, etc.

Where patients use terms that are subject to interpretation, clarify the meaning. Words like diarrhoea, constipation, nausea, heartburn, etc., mean different things to different people. People are also frequently embarrassed about bodily functions such as defecation, and will use euphemisms that are even more idiosyncratic.

Use the interview to show that as a professional you are knowledgeable, interested and non-judgemental, and give the patient the opportunity to talk freely, possibly for the first time, about their symptoms.

KEY POINT

• Always clarify the meaning of symptoms, as certain terms are subject to interpretation.

Gastrointestinal s ymptoms

Disorders of the gastrointestinal system may present with a wide range of symptoms. When enquiring about gastrointestinal illness it is worth asking specifically about certain symptoms, even if only to have a confirmed negative. The following list could guide the consultation:

• Dry mouth (xerostomia) or painful mouth.
• Excess salivation (waterbrash).
• Altered taste sensation (dysgeusia) or smell.
• Bad breath (halitosis).
• Lump in the throat (globus).
• Difficulty with swallowing (dysphagia).
• Pain on swallowing (odynophagia).
• Nausea and vomiting.
• Heartburn and reflux: epigastric or retrosternal burning or acid indigestion.
• Abdominal pain or discomfort.
• Dyspepsia: epigastric discomfort particularly related to eating.
• Bloating or abdominal distension.
• Hiccups.
• Excessive belching or flatulence.
• Diarrhoea: increased frequency or volume of stool, or looser motions.
• Urgency of defecation.
• Incontinence of faeces or flatus.
• Constipation: reduced frequency or volume of stool, difficulty passing stool.
• Incomplete evacuation (tenesmus).
• Defecation difficulty.
• Any altered bowel habit.
• Any altered stool character.
• Rectal bleeding: fresh or altered blood or melaena stool.
• Loss of weight.
• Change in appetite: loss of appetite, increased appetite.
• Jaundice.
• Itch (pruritis).

Painful mouth

Causes of a painful mouth include infections, trauma, vitamin deficiency, medications, systemic disorders and dermatological conditions. Gastrointestinal disorders causing painful mouth ulceration include coeliac disease and inflammatory bowel disease. Idiopathic apthous ulcers may run in families and be exacerbated by menstruation.

Box E Causes of a painful mouth

• Infection: candidiasis, herpes simplex, ulcerative gingivitis, infectious mononucleosis
• Trauma: dentures or teeth
• Medication: cytotoxic drugs, sulphonamides
• Vitamin deficiency: vitamin B12, folate, iron
• Ulceration from systemic disease: inflammatory bowel disease, coeliac disease, Behçet ' s disease
• Dermatological condition: lichen planus, erythema multiforme, pemphigoid and pemphigus
• Malignant: leukoplakia, carcinoma
• Idiopathic: apthous mouth ulcers

Dysphagia and odynophagia

Key factors to define are:

1 Level of swallowing difficulty : oropharangeal dysphagia causes difficulty in initiating a swallow, problems within a second of initiating a swallow or repeated attempts at swallowing. Oesophageal dysphagia causes difficulty in swallowing seconds after initiating a swallow.

2 Type of swallowing difficulty : this may be for solids, liquids or both. Swallowing solids with ' sticking ' and impact pain suggests a mechanical cause such as a stricture. Difficulty with liquids with spluttering and repeated swallows may represent a high pharyngeal cause. Nasal regurgitation, spluttering and aspiration may be due to achalasia or a pharyngeal pouch. A pouch may also cause bulging of the neck, gurgling or a nocturnal cough. The inability to swallow both solids and liquids may be a feature of oesophageal dysmotility or a more worrisome oesophageal carcinoma; the order of symptoms, speed of onset and associated alarm features are important to differentiate this.

3 Duration and pattern of swallowing difficulty : the duration and progression of dysphagia will determine if this is a benign or malignant process. A short progressive history is more suggestive of malignancy. A longer history intermittently over years suggests a more benign cause such as oesophageal dysmotility or an oesophageal web.

4 Pain on swallowing (odynophagia) : retrosternal chest pain on swallowing is characteristic of inflammatory disorders of the oesophagus. This may be the result of oesophageal candidaisis, herpes simplex oesophagitis, severe ulcerated reflux oesophagitis, oesophageal spasm or achalasia.

5 Previous history of reflux disease or swallowing disorder.

!RED FLAG

The following symptoms should act as an alarm:

• Unintentional weight loss.
• Short history of progressive dysphagia.

Predisposing f actors for d ysphagia

• Foreign body (fibrous or dry foods, tablets, solid objects).
• Corrosive material.
• Prolonged acid reflux and heartburn.
• Medication: bisphosphonates, non-steroidal antiinflammatory drugs (NSAIDs), steroid inhalers.
• Smoking.
• Alcohol consumption.
• Previous history of Barrett's or peptic stricture.
• Neck surgery or radiotherapy.
• Connective tissue disease such as scleroderma.
• Neurological disorder with a bulbar palsy.
• Family history of gastrointestinal malignancy or familial tylosis.

Complications of dysphagia

• Aspiration of oesophageal contents into the bronchial tree.
• Oesophageal rupture or tear.

Nausea and vomiting

Nausea and vomiting may be caused by gastrointestinal disorders or conditions affecting other organ systems. In most cases, vomiting is preceded by nausea, but in the case of intracranial tumour or hyperemesis of pregnancy, there may be no warning. Vomiting may also be self-induced in cases of bulimia or to relieve symptomatic pain or satiety. A careful description of what is meant by each of these terms is required.

Features of history

• Duration of symptoms.
• Timing and frequency of vomiting, such as early morning.
• Contents of vomit, taste, colour, quantity and smell. Bile is yellow-green and bitter and from the distal duodenum. Faeculant vomit is brown and malodorous suggesting small bowel of colonic obstruction or a fistula.
• Presence of blood: fresh red blood may arise from an oesophageal lesion, dark blood with clots suggests profuse bleeding from a peptic ulcer or varicies, coffee ground vomit is altered blood due to gastric acid exposure. Also ask if there was intense retching prior to this, suggesting a Mallory-Weiss tear.
• Exacerbating factors, such as certain foods or smells.
• Relieving factors.

Associated gastrointestinal symptoms that may give a clue about aetiology

• Swallowing difficulties: perhaps a pouch or stricture is present.
• Abdominal pain or discomfort, such as in peptic ulceration, pancreatitis and gallstones.
• Refux of acid or heartburn in ulcer disease.
• Loss of appetite or weight: think malignancy and malabsorption.
• Jaundice with or without pruritis in hepatobiliary disease.
• Fever or rigors
• Change in colour of the stools or urine.
• Change in bowel habit.

Associated non-gastrointestinal symptoms that may give aclue about aetiology

• Menstrual disturbance: could patient be pregnant?
• Neurological symptoms: headaches, visual disturbance, neck stiffness, weakness or paraethesia, vertigo.
• Disorder of hearing or balance in labyrnthitis or Meniére's disease.
• Excessive thirst or urination, indicating diabetes.
• Rash...