CHAPTER 1 7 Gastroenterological problems Elicit an accurate history Examine the patient Gastroenterological disease can cause systemic symptoms Systemic disease can cause gastroenterological symptoms 8 CHAPTER 1 Gastroenterological problems Introduction Food sticking after swallowing has started – oesophageal dysphagia Gastroenterological problems encompass the This suggests the presence of a structural lesion in entire range of pathology, including neoplasm, the oesophagus. Some patients can actually infection, inflammation, immunological localize the level of food sticking, while others disorders, biochemical, metabolic and congenital cannot. conditions, and disorders of unknown cause. The nature of food that elicits symptoms In addition, approximately one-third of the should be clarified. Dysphagia initially for liquids gastrointestinal symptoms of outpatients have no is more likely to reflect problems in muscular or identifiable structural, infective, or biochemical neural control of swallowing. Dysphagia initially disorder present – they appear as ‘functional for solids is likely to reflect a structural lesion in disorders’. Within such disorders, psychological the oesophagus. Progressive dysphagia, first for or social factors may be primarily responsible. solids, then for sloppy food and liquids, is a Identification and correct management depends sinister sign that is strongly suggestive of cancer on accurate history taking, clinical examination, of the oesophagus, although this can occur with and specialist investigations. peptic strictures from recurrent oesophagitis. Nonprogressive dysphagia may suggest a Approach to the patient benign structural lesion (e.g. mucosal web in upper oesophagus, benign ‘ring’ in lower Some cardinal symptoms focus attention on one oesophagus). Intermittent food sticking, particular organ, and dictate the most effective affecting both solids and liquids, suggests and economical investigational path. Be aware disordered motility (achalasia, oesophageal that some disease processes outside the abdomen spasm). may present with abdominal symptoms, and With any oesophageal obstruction, consider the patient as a whole. regurgitation of food and liquid into the mouth may occur. The fluid is bland and not bitter, Major presenting as it does not contain gastric acid. Nocturnal complaints regurgitation may be associated with choking, aspiration, pneumonia, or asthma. DIFFICULTY IN SWALLOWING (DYSPHAGIA) Lump in throat (globus hystericus or Difficulty in transferring food from the mouth to globus sensation) the stomach is termed dysphagia. This is an During stress, highly anxious individuals may important symptom and it is useful to distinguish complain of a sensation of a lump in the throat between the two phases of the normal swallow. without having eaten or drunk, often with The initial oropharyngeal phase, during which a temporary inability to swallow. This is a food bolus is moved from the mouth to the temporary functional disorder associated with oesophagus, is under voluntary control. This is anxiety. It is more common in women and, followed by the oesophageal phase, which is although investigations are frequently normal, it involuntary. is sometimes associated with other oesophageal conditions (reflux disease and motility disorders). Difficulty in starting the swallow – Gastropharyngeal reflux accounts for the oropharyngeal dysphagia symptoms in some. This relates to neurological or muscular diseases (bulbar, pseudobulbar palsy, motor neurone LOSS OF APPETITE disease, myasthenia gravis). It is often associated This is highly nonspecific, but may be functional with drooling due to difficulty in swallowing if associated with anxiety or depression. When saliva, or aspiration of saliva and aspiration associated with weight loss, it suggests significant pneumonia. There may be associated problems organic disease. A maintained appetite is a with voice production. reassuring sign that serious disease is less likely to Major presenting complaints 9 be found. Early satiety (initial hunger but a rapid PAIN feeling of fullness after commencing eating) may This is the most common reason for referral to reflect a poorly distensible stomach or a motility gastroenterologists. Classic symptom complexes disorder. are sometimes recognizable, but some pains are poorly characterized and localized. The site NAUSEA AND VOMITING and radiation of pain should be defined, and These are nonspecific symptoms. In young its duration (minutes or hours) noted. Pain men, morning nausea and retching without character should also be noted – is the pain vomiting strongly suggests alcoholism. In sharp, dull, or intermittent? Periodicity details young women, morning nausea suggests should be noted – whether pain occurs all day, pregnancy. Nausea occurs with many occasionally but every day, or every day for some abdominal pains, particularly those reflecting weeks and then not at all for some months, spasm of smooth muscle. Examples include an is important diagnostically. Timing and obstructed biliary tract, or spasm of the colon in relationship of pain to eating, defaecation, and functional bowel disease. Vomiting is a more sleep should be noted. Relieving factors should significant disturbance involving reverse be elucidated, and associated symptoms elicited peristalsis and expulsion of gastric contents. It (e.g. vomiting, nausea, weight loss). Major is rare as a purely functional disorder, although patterns of pain are described below. in a few patients ‘hysterical vomiting’ is the final diagnosis, generally reflecting severe family Heartburn (pyrosis) stress. More often, vomiting reflects organic This is best reserved to describe sensations that disease affecting the stomach, duodenum, or occur when gastric acid refluxes into the small intestine. oesophagus, but patients use the term in different Short-lived vomiting with fever and diarrhoea contexts. There is a raw burning sensation, suggests food poisoning (bacteria, bacterial retrosternally, lasting for some minutes, which toxins, viral gastroenteritis). may start in the epigastrium and travel back to the Prolonged vomiting over more than a few throat. Heartburn is precipitated by large meals, days needs further investigation. In the absence alcohol, stooping, or lying flat in bed. It is rapidly of pain, persistent vomiting suggests obstruction relieved by drinking milk/alkali. Persistent severe of the outflow tract of the stomach, as seen with heartburn suggests the presence of oesophagitis antral carcinoma or narrowing of the pylorus due (inflammation in the oesophagus) and repeated to long-standing duodenal ulceration. reflux. When severe, dysphagia may result. The The nature of vomitus may be significant. condition may eventually be complicated by Vomiting food ingested many hours previously stricture. Reflux is often, but not invariably, suggests obstruction of the gastric outlet, as the associated with hiatus hernia. stomach normally empties within 4–6 hr of eating. Vomiting of blood is discussed below. Dyspepsia Vomiting must be distinguished from Epigastric pain altered by food intake is the regurgitation (food returning to mouth from classical symptom of peptic ulceration. gullet without reverse peristalsis), and from Symptoms of duodenal and gastric ulceration, waterbrash (the mouth filled with salty water due duodenitis, and gastritis all overlap and are not to excess saliva, sometimes a symptom of peptic distinguishable without investigation. Often, ulceration). epigastric discomfort related to food is Both vomiting and nausea can reflect events associated with negative findings on further elsewhere in the body (e.g. raised intracranial examination, particularly in anxious patients. pressure, severe metabolic complications such as The classical duodenal ulcer history is epigastric renal failure, side effects of drugs). Prolonged pain, which is relieved by food and brought on vomiting can induce metabolic changes, for by hunger; the pain is epigastric or radiating example hypokalaemic alkalosis and secondary through to the back. Antacids relieve symptoms potassium loss from the kidneys. usually within minutes. The pain often wakes 10 CHAPTER 1 Gastroenterological problems the patient in the early hours. Symptoms may Small-intestinal colic is poorly localized but come in bouts (daily for several weeks and then predominantly central and above the umbilicus. remitting for months or years). Associated Colonic colic is characteristically low in the nausea and vomiting may be prominent with abdomen, below the umbilicus, and is relieved gastric ulcers or prepyloric ulcers. by defaecation. Intestinal inflammation can be painful. Transmural inflammation with Gallbladder and biliary pain secondary inflammation of parietal peritoneum, Pain from the biliary tract reflects either spasm of e.g. appendicitis, gives well-localized pain over smooth muscle or acute inflammation. Spasm is the inflamed organ, but is worse on movement due to obstruction of the common bile duct or or prodding. the neck of the gallbladder, usually by a gallstone. The full-blown syndrome of biliary colic is Severe acute abdominal pain unmistakable – severe right upper quadrant A number of rare causes should be considered in pain, radiating laterally to the back, in waves addition to classical surgical emergencies of superimposed on a severe discomfort. This lasts obstruction or perforation. Consider coronary for several hours, generally with nausea and artery insufficiency (angina or myocardial vomiting.