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Home , Abdominal pain, Ascites, Biliary colic, Drooling, Dysphagia, Oropharyngeal dysphagia

CHAPTER 1 7 Gastroenterological problems

Elicit an accurate history

Examine the patient

Gastroenterological can cause systemic symptoms

Systemic disease can cause gastroenterological symptoms 8 CHAPTER 1 Gastroenterological problems

Introduction Food sticking after has started – oesophageal Gastroenterological problems encompass the This suggests the presence of a structural lesion in entire range of pathology, including , the oesophagus. Some patients can actually infection, , 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 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 spasm). may present with abdominal symptoms, and With any oesophageal obstruction, consider the patient as a whole. regurgitation of food and liquid into the 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, , or asthma. DIFFICULTY IN SWALLOWING (DYSPHAGIA) Lump in throat (globus hystericus or Difficulty in transferring food from the mouth to globus sensation) the 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 symptoms in some. This relates to neurological or muscular (bulbar, , motor neurone LOSS OF APPETITE disease, ). It is often associated This is highly nonspecific, but may be functional with due to difficulty in swallowing if associated with anxiety or depression. When , 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 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 are poorly characterized and localized. The site AND 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 . In sharp, dull, or intermittent? Periodicity details young women, morning nausea suggests should be noted – whether pain occurs all day, . 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 , 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 (pyrosis) stress. More often, vomiting reflects organic This is best reserved to describe sensations that disease affecting the stomach, , or occur when gastric acid refluxes into the . oesophagus, but patients use the term in different Short-lived vomiting with and diarrhoea contexts. There is a raw burning sensation, suggests food poisoning (bacteria, bacterial retrosternally, lasting for some minutes, which toxins, viral ). 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 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 . 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 , and 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 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 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 and biliary pain secondary inflammation of parietal , Pain from the biliary tract reflects either spasm of e.g. , 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 duct or or prodding. the of the gallbladder, usually by a . The full-blown syndrome of is Severe acute 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. Patients classically roam around to find can be epigastric). Aortic disease – a comfortable position. An inflamed gallbladder dissection, aneurysm, or dilatation – may give () gives similar sited pain, though it epigastric pain. Intestinal ischaemia can cause is more likely to radiate to the shoulder. Minor recurrent noncolicky pain induced by eating, discomfort is attributed to postprandial with characteristic weight loss as food is avoided contraction of the gallbladder (right upper due to fear of pain. Metabolic disorders (acute quadrant discomfort, excessive belching, nausea) intermittent ) comprise a rare but but these are often nonspecific. important cause.

Pancreatic pain Chronic inflammation gives severe pain in the Gut bleeding varies from acute and life- back just below the shoulder blades, brought threatening, to chronic and trivial. Most about by eating or alcohol, and mildly relieved bleeding comes from the upper by leaning forward. This history is also , presenting either with compatible with duodenal ulceration. Much haematemesis and melaena, or just melaena. pancreatic pain is ill-defined – dyspepsia The source is variable, from oesophagus to affecting the epigastrium, or right or left side of upper . Lower gastrointestinal the abdomen, and with an indefinite relationship haemorrhage is less common as an emergency, to food. may be painless, but and varies from trivial haemorrhoids (bright extension retroperitoneally initiates unremitting red bleeding on toilet paper after defaecation) central . to more severe causes – cancer, polyps, diverticular disease and vascular malformation, Intestinal pain or inflammatory in association with Normal peristalsis is painless. Short-lived, acute diarrhoea. Bleeding from the distal colon is painful peristalsis – intestinal colic – is readily normally fairly bright red, but from the recognized, usually due to acute gastroenteritis. caecum is plum-coloured or darker. Low- Repeated or persistent painful peristalsis generally grade chronic blood loss may be invisible indicates intestinal narrowing or obstruction, (occult) and present with anaemia. most commonly due to adhesions and previous or tumours. There is intermittent sharp ABNORMAL BOWEL HABIT exacerbation of pain, doubling up the patient Normal bowel habit varies between people, from when pain is severe. The full-blown picture of two or three loose stools daily to hard motions complete obstruction is a constellation of crampy every second or third day. Changes in pre-existing pains, distension, borborygmi (audible, high- pattern are more significant than long-standing pitched bowel sounds), nausea, and eventually deviation from what the patient or doctor failure to pass bowel motions or flatus. considers ‘normal’. Major presenting complaints 11

Constipation with crampy abdominal colic, but disease of the This is described as infrequent passage of stools, small intestine can also cause colonic colic as which become dehydrated and hard from a long excess fluid enters the colon. Under normal stay in the colon (see Chapter 10). Trivial causes circumstances, less than 1.25 l of intestinal fluid include immobility, diminished food intake, and leaves the to enter the colon, which then with constipating agents, e.g. reduces the volume to less than 300 ml. Liquid codeine. requires further stool volumes of more than 1.5 l a day, therefore, investigation when recent in origin or strongly suggest disease of the small gut. associated with colicky pain. RECTAL SYMPTOMS Diarrhoea Symptoms from the include: This requires careful definition. Diarrhoea may • Tenesmus: this refers to a feeling of rectal describe states from moderate to frequent fullness and a sensation that the bowel needs passage of formed stools, to massive volumes of evacuation (even if a bowel motion has liquid stool. Many patients with a ‘diarrhoeal’ recently been passed). It reflects the presence form of irritable bowel have two to three loose of rectal inflammation. motions in the morning, usually after food, but • Constant anal pain (suggesting the presence the total mass of stool is normal. Diarrhoea of an or thrombosed haemorrhoid). waking a patient at night is generally significant. • A tearing pain on defaecation (suggesting an Passage of blood and mucus is obviously ). significant, but passage of mucus alone does not • : an intense intermittent anal indicate pathology. Clinical indications of pain attributed to spasm. steatorrhoea (pale, floating, foul-smelling) (1) • : anal , which occurs are unreliable indicators of excess fat idiopathically or in the presence of (). Observation of rainbow infection. colours on the surface of the stool or lavatory pan water implies severe steatorrhoea – such as seen WEIGHT LOSS in pancreatic insufficiency or extensive resection In combination with other gastrointestinal of the small gut. Inflammatory colitis, or symptoms, this is a major symptom. Systemic ischaemic change in the colon, is often associated conditions (thyrotoxicosis, , , cancer, and anxiety) should also be considered.

OTHER GASTROINTESTINAL SYMPTOMS Other less well-defined complaints should be 1 considered. , particularly after meals, is one classical manifestation of functional bowel disease, probably reflecting delayed emptying of small-intestinal contents into the caecum. Other symptoms include alternation between constipation and diarrhoea, colicky colonic pain, and intermittent discomfort in the right upper quadrant, left upper quadrant, or left lower quadrant of the abdomen. Long- standing symptoms in the presence of otherwise good health, dating back many years, or persistent abnormality of bowel habit following 1‘Silver stool’ – the pale steatorrhoeic stool, an acute attack of gastroenteritis, are suggestive together with the presence of altered blood, in a clinical features for diagnosis of irritable bowel patient with a combination of obstructive syndrome. and bleeding into the gut. 12 CHAPTER 1 Gastroenterological problems

Functional Clinical features gastrointestinal The features of are syndromes variable and frequently fluctuate. There may be a history of diarrhoea or constipation, or Many patients present with symptoms that seem alternation between these patterns. Abdominal to arise from the gastrointestinal tract, but for pain tends to accompany the changes in bowel which no specific structural explanation is habit. Features such as rectal bleeding, nocturnal apparent. These are termed functional symptoms, or systemic symptoms such as weight gastrointestinal syndromes. They are common in loss should lead to a consideration of other the general population and account for a large diagnoses. proportion of new referrals to gastrointestinal outpatient clinics. Typically, there are other Management symptoms in other systems, for example A proactive approach to making the diagnosis gynaecological symptoms or fibromyalgia. As a with the minimum of investigation is better than group, patients score highly in indices of making irritable bowel syndrome a diagnosis of depression and anxiety, although individual exclusion. Careful and reassuring explanations of patients do not usually meet the criteria for formal the benign nature of the condition are frequently psychiatric diagnosis. helpful.

IRRITABLE BOWEL SYNDROME Drug therapy Definition This is led by the dominant symptoms. Diarrhoea Irritable bowel syndrome is characterized by is treated with antidiarrhoeal drugs such as chronic abdominal pain, associated with an loperamide. Antispasmodic drugs are frequently altered bowel habit in the absence of an organic prescribed, although there is little evidence of cause. efficacy. Low-dose tricyclic antidepressants are used particularly for abdominal pain, and seem to Epidemiology have an action independent of anxiety or There is a common constellation of symptoms, depression. Global symptom improvement has reported by around 20% of the general been reported with selective serotonin reuptake population in surveys. However, most sufferers inhibitors (SSRIs). do not seek medical attention. The disease is mostly diagnosed in young adults, and more frequently in women (female:male 2:1). Familial clustering has been noted in some studies, either representing heritable pathophysiological changes or an environmental contributor.

Aetiology The aetiology of irritable bowel syndrome is not known. There are a number of theories, including changes in perception, alteration of motility, and bacterial overgrowth. Frequently, patients give a history of an antecedent infective gastroenteritis. Psychological dysfunction (typically anxiety, depression, and somatization) is over-represented in patients referred to tertiary care centres, but is insufficient to meet criteria for formal psychiatric diagnosis. of the patient 13

Physical examination of the gastroenterology An enlarged, tender liver may be inflamed, patient congested, or the site of an abscess or tumour. The patency of the hepatic venous drainage can The historical features outlined above will have be checked by showing elevation of the jugular suggested a short . In many venous pressure on pressing over the liver. patients with , no Although a crude physical sign, there is a good abnormal physical findings will be demonstrable. correlation between the finding of a fibrous, hard Nonetheless, a physical examination, which liver and . Rapid changes in liver size may should not be confined to the abdomen, should indicate mobilization of fat, and in alcoholic be made. Aspects of the general physical patients the liver may diminish in size rapidly on examination that may provide useful clues to abstention from alcohol. A hepatic bruit may be gastroenterological and hepatic conditions are heard in alcoholic or in patients with given in Table 1 (2–8). tumours.

Table 1 General physical signs of gastrointestinal disease Hands Liver palms Acute or chronic Clubbing (2, 3) Cirrhosis, Crohn’s disease Leukonychia (white nails) Liver disease, protein-losing Dupuytren’s contracture Alcoholism Skin Spider naevi Cirrhosis or hepatitis White spots (4) Pigmentation (4) Haemochromatosis, internal , malabsorption Blisters, depigmentation Porphryia cutanea tarda Erythema nodosum (5) Inflammatory bowel disease Eyes Coloration Jaundice (6) Episcleritis (7)/iritis Inflammatory bowel disease (3) Retinal appearances Pseudoxanthoma elasticum Venous pressure Hepatic pain in congestive cardiac failure Cardiological causes of or protein-losing enteropathy Carcinoma of the stomach and other Cyanosis Severe liver disease Anaemia Acute and chronic gastrointestinal blood loss Cardiac disease and peripheral pulses Intestinal angina, ischaemic gut disease, mesenteric emboli Gynaecomastia Chronic liver disease Alcoholism, , porphyria, vitamin

B12 deficiency due to malabsorption Liver disease Erythema ab igne (8) (mottled pigmentation of the skin due to application of external heat) 14 CHAPTER 1 Gastroenterological problems

2 3

2 Clubbing of the fingers. 3 Clubbing and multiple scars point to chronic inflammatory bowel disease.

4 5

5 Erythema nodosum, seen in Crohn’s disease or .

4 Gynaecomastia, ascites, and pigmentation all point to chronic liver disease in this patient. Physical examination of the gastroenterology patient 15

6 7

6 Jaundice; xanthelasma around the eyes in 7 Episcleritis, another association of active chronic cholestatic jaundice (primary biliary inflammatory bowel disease. cirrhosis).

8 Erythema ab igne, due to applied heat in an 8 attempt to relieve chronic pain in a patient with a narrow terminal ileum causing recurrent abdominal pain.

SPLEEN ABDOMINAL BRUITS Palpating the can be difficult. Rotating the Bruits in the epigastrium are not necessarily patient on to the right side, a helping examiner’s pathological, as the superior mesenteric artery hand on the left flank, and deep inspiration may may often be stretched over the . all make the examination easier. Nonetheless, they should lead to consideration of a diagnosis of intestinal ischaemia or a pancreatic ASCITES tumour. While gross ascites is easy to detect (4, 333), one may be misled into diagnosing ascites in gross HERNIAL ORIFICES, SCARS obesity, as fat is liquid at body temperature. Minor Hernial orifices and scars are relevant in the degrees of ascites can be difficult to detect context of colicky abdominal pain, as they may clinically, but ultrasound examination will settle indicate obstruction in the hernial sac or the any doubt. presence of adhesions.