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Upper GI Symptoms (524) © Copyright 2003 by the International Foundation for Functional Gastrointestinal Disorders Confusing or Ambiguous Upper Gut Symptoms By: W. Grant Thompson M.D., F.R.C.P.C., F.A.C.G., Professor Emeritus, Faculty of Medicine, University of Ottawa, Ontario, Canada

By choosing the appropriate test, a doctor can make a Gas precise diagnosis of a structural upper gut disorder, such as Every human contains gas that or peptic ulcer, by recognizing the diseased occasionally escapes to the outer world through the mouth area through testing. The patient’s history provides the or anus. However, gas has come to mean different things to information that permits the doctor to choose the right test. different people. Someone who belches or burps feels “full In the case of the disorders of gastrointestinal function, of gas.” Another person suffering the release of gas from such as dyspepsia or non-cardiac chest pain, there is no the other end may use the term gas euphemistically, too structural abnormality and no diagnostic test. Hence embarrassed to describe gas escaping from the anus – and diagnosis of these disorders depends even more upon how too discreet to use a slang term. Still another may feel the patient describes his or her symptoms. bloated or distended and say they are “full of gas.” This is Many people use words to describe their gut symptoms especially common in women. Worsening during the day, that are ambiguous or misleading. Since these terms are the connection of this symptom with intestinal gas is poorly unhelpful in identifying the problem they should be understood. Noises from the stomach, frequently described avoided or explained carefully. The following are some as growling or grumbling sounds, are known medically as examples. borborigmi. These sounds are the result of air gurgling with liquids as it passes through the ever-moving intestines. Fortunately these gas scenarios are seldom signs of serious A medical dictionary defines indigestion as “incomplete or disease. Nevertheless, they can be annoying and worrying, imperfect digestion, usually accompanied by one or more so it is important that the doctor know how the symptoms of the following symptoms: pain, and vomiting, of gas manifest so he or she can interpret the complaint. heartburn and acid regurgitation, accumulation of gas and belching.” I have even heard the term used to denote Nausea and . Apparently indigestion can Nausea is “the unpleasant feeling of sickness that often include almost the entire repertoire of gut symptoms. precedes vomiting.” It’s not that nausea is imprecise – we Consequently the term is of little use to a doctor all know what it feels like. The problem is that nausea is endeavoring to analyze a patient’s history in order to make associated with so many disorders and circumstances that a diagnosis or plan appropriate tests. For this reason the by itself it has no diagnostic significance. Seasickness or term is best avoided. the nausea of pregnancy are obvious only if the doctor Dictionaries state that dyspepsia is a synonym for knows the appropriate history. Nausea very often, but not indigestion. Used colloquially therefore, the term is equally always, precedes or accompanies vomiting. The disorders useless. In fact few lay people use the term at all. causing nausea are as varied as motion sickness (middle Gastroenterologists have defined dyspepsia more narrowly ear), intestinal obstruction, diseases affecting the brain, as a “pain or discomfort centered in the upper abdomen.” drug side effects, hormonal changes, and fright or anxiety Such a pain is found in or nonulcer states. Sometimes the sight of a food can nauseate. If a dyspepsia and must be differentiated from pains of other person’s main complaint is nausea, only the associated upper abdominal complaints. Dyspepsia is a symptom circumstances, symptoms, and medications can help the complex or diagnosis recognized by doctors, but unhelpful doctor search for the cause. when complained of by patients. Thus neither complaints of indigestion nor dyspepsia Vomiting are of any diagnostic use, and patients should avoid these Vomiting seems an easy symptom to understand. It is the terms in a medical interview. It is preferable to describe in return of gastric contents including food and gastric acid a few words the characteristics of the actual pain, from the stomach through the mouth. However, there are discomfort, or gastrointestinal upset in order to help doctors some lesser-known symptoms sometimes confused with determine what part of the gut is dysfunctioning and what vomiting. Regurgitation of acid and food into the the diagnostic possibilities might be. may occur due to a weakness in the lower esophageal sphincter. This is called gastroesophageal reflux – the fundamental abnormality underlying GERD. Chest Pain Unlike vomiting, the regurgitated material returns to the There are many causes of chest pain, some very serious, stomach without being ejected through the mouth. In both and few are connected to the gut (See IFFGD Fact Sheet cases the patient may experience heartburn as a result of the No. 517, Unexplained Chest Pain.) The primary concern is acid in the esophagus. A rarer type of regurgitation is that chest pain might be due to heart disease. That is why it known as rumination. Here a person regurgitates the meal is very important to be as precise as possible about the from the stomach into the mouth and then swallows it again nature of the symptom. Is the pain worse after exercise? with neither discomfort nor concern. The meal is returned Does it occur when walking a certain distance, disappear promptly before it is mixed with acid, so the ruminator with rest, and then recur when the certain distance is suffers no heartburn. walked again? Pain resulting from injury to the muscles or Sometimes excess production of saliva by glands in the bones of the chest wall will worsen with certain movements mouth may accompany upper abdominal symptoms such as of the trunk. Pleurisy, an inflammation of the lining of the nausea or heartburn. Unlike vomiting, the saliva does not lung, will be sharply worse with inhaling or exhaling. If the burn and is usually swallowed. This is known as pain is due to esophageal disease, then a relationship with waterbrash. swallowing, with meals, or an association with acid regurgitation is usually present. Characteristically, acid- Hiatal related pain is relieved by antacids and most dramatically In many people, the junction between the esophagus by the proton pump inhibitors. (gullet) and stomach “herniates” up through the diaphragm The details surrounding upper gut symptoms are often into the chest cavity. This phenomenon may be temporary very important in arriving at a correct and timely diagnosis. or permanent, and is often cited as one of the causes of Therefore describe symptoms such as chest pain with care. gastroesophageal reflux disease (GERD). However, hiatal [None of these are specific, however, and further evaluation hernia [also referred to as hiatus hernia] is an anatomical is always required; cardiac disease must be ruled out.] abnormality, not a symptom, and its presence or absence Your life could depend upon it. does not equate with the symptoms of GERD. Rather than complaining of “my ,” it is more precise to Suggested Reading describe the sensation itself. The most common symptom is 1. Thompson WG. Glossary. Pgs. 637-657. In: Drossman heartburn – a burning sensation behind the breastbone. A DA, Corazziari E, Talley NJ, Thompson WG, careful description of heartburn, and noticing what makes it Whitehead WE, (Eds.). The functional gastrointestinal worse (lying down, large meals, effort, etc) is very helpful disorders. McLean, VA: Degnon Associates. 2002. to a physician who will diagnose it as GERD, not hiatal hernia. 2. Thompson WG, Longstreth GF, Drossman DA, Heaton KW, Irvine EJ, Muller-Lissner SA. Functional bowel disorders and functional abdominal pain. In: Drossman Symptoms of GERD DA, Corazziari E, Talley NJ, Thompson WG, Whitehead WE, (Eds.). The functional gastrointestinal Chronic heartburn is the most common disorders. MacLean, VA: Degnon Associates. 2000. symptom of GERD. Acid regurgitation (refluxed material into the mouth) is another common symptom. But numerous less common symptoms other than heartburn may be About IFFGD associated with GERD. These may include: The International Foundation for Functional Gastrointestinal  Belching Disorders (IFFGD) is a 501(c)(3) nonprofit education and research organization. We work to promote awareness, scientific  Difficulty or pain when swallowing advancement, and improved care for people affected by chronic  Waterbrash (sudden excess of saliva) digestive conditions. Our mission is to inform, assist, and support  (the sensation of food sticking in people affected by gastrointestinal disorders. Founded in 1991, we the esophagus) rely on donors to carry out our mission. Visit our websites at: www.iffgd.org or www.aboutGERD.org.  Chronic sore throat  Laryngitis About the Publication  Inflammation of the gums Opinions expressed are an author’s own and not necessarily those of the International Foundation for Functional Gastrointestinal  Erosion of the enamel of the teeth Disorders (IFFGD). IFFGD does not guarantee or endorse any product  Chronic irritation in the throat in this publication or any claim made by an author and disclaims all liability relating thereto. This article is in no way intended to replace  Hoarseness in the morning the knowledge or diagnosis of your doctor. We advise seeing a  A sour taste physician whenever a health problem arises requiring an expert’s  Bad breath care.

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