The gastrointestinal system

Mouth symptoms

Bad breath (halitosis) due to gingival, dental or pharyngeal infection and dry mouth (xerostomia) are common mouth symptoms. Rarely patients complain of altered taste sensation (dysgeusia) or a foul taste in the mouth (cacogeusia).

Anorexia and weight loss

Anorexia is a loss of appetite and/or a lack of interest in food. In addition to enquiring about appetite, ask ‘Do you still enjoy your food?’

Weight loss, in isolation, is rarely associated with serious organic disease. Ask how much weight has been lost, over what time. Loss of less than 3 kg in the previous 6 months is rarely significant. Weight loss is usually the result of reduced energy intake, not increased energy expenditure. It does not specifically indicate gastrointestinal disease, although it is common in many gastrointestinal disorders, including malignancy and liver disease. Energy requirements average 2500 kcal/day for males and 2000 kcal/day for females. Reduced energy intake arises from dieting, loss of appetite, malabsorption or malnutrition. Increased energy expenditure occurs in hyperthyroidism, fever or with the adoption of a more energetic lifestyle. A net calorie deficit of 1000 kcal/day results in weight loss of approximately 1 kg/week (7000 kcal ≅ 1 kg of fat). Greater weight loss during the initial stages of energy restriction arises from salt and water loss and depletion of hepatic glycogen stores, not from fat loss. Rapid weight loss over days suggests loss of body fluid as a result of vomiting, diarrhoea or diuretics (1 L of water = 1 kg). Check current and previous weight records to confirm apparent weight loss on examination (loose-fitting clothes, for example).

Pain

Abdominal pain

Characterise the pain using the acronym SOCRATES (see Box 2.2 ). Ask about the characteristics described here.

Site

Visceral abdominal pain from distension of hollow organs, mesenteric traction or excessive smooth-muscle contraction is deep and poorly localised in the midline. The pain is conducted via sympathetic splanchnic nerves. Somatic pain from the parietal peritoneum and abdominal wall is lateralised and localised to the inflamed area. It is conducted via intercostal nerves.

Pain arising from foregut structures (stomach, pancreas, liver and biliary system) is localised above the umbilicus ( Fig. 6.4 ). Central abdominal pain arises from midgut structures, such as the small bowel and appendix. Lower abdominal pain arises from hindgut structures, such as the colon. Inflammation may cause localised pain: for example, left iliac fossa pain due to diverticular disease of the sigmoid colon.

Pain from an unpaired structure, such as the pancreas, is midline and radiates through to the back. Pain from paired structures, such as renal colic, is felt on, and radiates to, the affected side ( Fig. 6.5 ). Torsion of the testis may present with abdominal pain (p. 267). In females, consider gynaecological causes such as ruptured ovarian cyst, pelvic inflammatory disease, endometriosis or ectopic pregnancy (p. 247).

Onset

Sudden onset of severe abdominal pain, rapidly progressing to become generalised and constant, suggests a hollow viscus perforation (usually due to peptic ulceration, diverticular disease or colorectal cancer), a ruptured abdominal aortic aneurysm or mesenteric infarction.

Torsion of the caecum or sigmoid colon (volvulus) presents with sudden abdominal pain associated with acute intestinal obstruction.

Character

Colicky pain lasts for a short time (seconds or minutes), eases off and then returns. It arises from hollow structures, as in small or large bowel obstruction, or the uterus during labour.

Biliary and renal ‘colic’ are misnamed, as the pain is rarely colicky; pain rapidly increases to a peak and persists over several hours before gradually resolving. Dull, constant, vague and poorly localised pain is more typical of an inflammatory process or infection, such as pelvic inflammatory disease, appendicitis or diverticulitis ( Box 6.2 ).

6.2

Diagnosing abdominal pain

	Disorder
	Peptic ulcer	Biliary colic	Acute pancreatitis	Renal colic
Site	Epigastrium	Epigastrium/right hypochondrium	Epigastrium/left hypochondrium	Loin
Onset	Gradual	Rapidly increasing	Sudden	Rapidly increasing
Character	Gnawing	Constant	Constant	Constant
Radiation	Into back	Below right scapula	Into back	Into genitalia and inner thigh
Associated symptoms	Non-specific	Non-specific	Non-specific	Non-specific
Timing
Frequency/periodicity	Remission for weeks/months	Attacks can be enumerated	Attacks can be enumerated	Usually a discrete episode
Special times	Nocturnal and especially when hungry	Unpredictable	After heavy drinking	Following periods of dehydration
Duration	1/2–2 hours	4–24 hours	>24 hours	4–24 hours
Exacerbating factors	Stress, spicy foods, alcohol, non-steroidal anti-inflammatory drugs	Eating – unable to eat during bouts	Alcohol Eating – unable to eat during bouts	–
Relieving factors	Food, antacids, vomiting	–	Sitting upright	–
Severity	Mild to moderate	Severe	Severe	Severe

Radiation

Pain radiating from the right hypochondrium to the shoulder or interscapular region may reflect diaphragmatic irritation, as in acute cholecystitis ( Fig. 6.5 ). Pain radiating from the loin to the groin and genitalia is typical of renal colic. Central upper abdominal pain radiating through to the back, partially relieved by sitting forward, suggests pancreatitis. Central abdominal pain that later shifts into the right iliac fossa occurs in acute appendicitis. The combination of severe back and abdominal pain may indicate a ruptured or dissecting abdominal aortic aneurysm.

Associated symptoms

Anorexia, nausea and vomiting are common but non-specific symptoms. They may accompany any very severe pain but conversely may be absent, even in advanced intra-abdominal disease. Abdominal pain due to irritable bowel syndrome, diverticular disease or colorectal cancer is usually accompanied by altered bowel habit. Other features such as breathlessness or palpitation suggest non-alimentary causes ( Box 6.3 ).

6.3

Non-alimentary causes of abdominal pain

Disorder	Clinical features
Myocardial infarction	Epigastric pain without tenderness Angor animi (feeling of impending death) Hypotension Cardiac arrhythmias
Dissecting aortic aneurysm	Tearing interscapular pain Angor animi Hypotension Asymmetry of femoral pulses
Acute vertebral collapse	Lateralised pain restricting movement Tenderness overlying involved vertebra
Cord compression	Pain on percussion of thoracic spine Hyperaesthesia at affected dermatome with sensory loss below Spinal cord signs
Pleurisy	Lateralised pain on coughing Chest signs (e.g. pleural rub)
Herpes zoster	Hyperaesthesia in dermatomal distribution Vesicular eruption
Diabetic ketoacidosis	Cramp-like pain Vomiting Air hunger Tachycardia Ketotic breath
Pelvic inflammatory disease or tubal pregnancy	Suprapubic and iliac fossa pain, localised tenderness Nausea, vomiting Fever
Torsion of testis/ovary	Lower abdominal pain Nausea, vomiting Localised tenderness

Hypotension and tachycardia following the onset of pain suggest intra-abdominal sepsis or bleeding: for example, from a peptic ulcer, a ruptured aortic aneurysm or an ectopic pregnancy.

Timing

During the first 1–2 hours after perforation, a ‘silent interval’ may occur when abdominal pain resolves transiently. The initial chemical peritonitis may subside before bacterial peritonitis becomes established. For example, in acute appendicitis, pain is initially periumbilical (visceral pain) and moves to the right iliac fossa (somatic pain) when localised inflammation of the parietal peritoneum becomes established. If the appendix ruptures, generalised peritonitis may develop. Occasionally, a localised appendix abscess develops, with a palpable mass and localised pain in the right iliac fossa.

A change in the pattern of symptoms suggests either that the initial diagnosis was wrong or that complications have developed. In acute small bowel obstruction, a change from typical intestinal colic to persistent pain with abdominal tenderness suggests intestinal ischaemia, as in strangulated hernia, and is an indication for urgent surgical intervention.

Abdominal pain persisting for hours or days suggests an inflammatory disorder, such as acute appendicitis, cholecystitis or diverticulitis.

Exacerbating and relieving factors

Pain exacerbated by movement or coughing suggests inflammation. Patients tend to lie still to avoid exacerbating the pain. People with colic typically move around or draw their knees up towards the chest during spasms.

Severity

Excruciating pain, poorly relieved by opioid analgesia, suggests an ischaemic vascular event, such as bowel infarction or ruptured abdominal aortic aneurysm. Severe pain rapidly eased by potent analgesia is more typical of acute pancreatitis or peritonitis secondary to a ruptured viscus.

Features of the pain can help distinguish between possible causes ( Box 6.3 ).

The acute abdomen

The majority of general surgical emergencies are patients with sudden severe abdominal pain (an ‘acute abdomen’). Patients may be so occupied by recent and severe symptoms that they forget important details of their history unless asked directly. Seek additional information from family or friends if severe pain, shock or altered consciousness makes it difficult to obtain a history from the patient. Note any relevant past history, such as known diverticular disease in a patient with a possible acute perforation. Causes range from self-limiting to severe life-threatening diseases ( Box 6.4 ). Evaluate patients rapidly, and then resuscitate critically ill patients immediately before undertaking further assessment and surgical intervention. Parenteral opioid analgesia to alleviate severe abdominal pain will help, not hinder, clinical assessment. In patients with undiagnosed acute abdominal pain, reassess their clinical state regularly, undertake urgent investigations and consider surgical intervention in a timely fashion.

6.4

Typical clinical features in patients with an ‘acute abdomen’

Condition	History	Examination
Acute appendicitis	Nausea, vomiting, central abdominal pain that later shifts to the right iliac fossa	Fever, tenderness, guarding or palpable mass in the right iliac fossa, pelvic peritonitis on rectal examination
Perforated peptic ulcer with acute peritonitis	Vomiting at onset associated with severe acute-onset abdominal pain, previous history of dyspepsia, ulcer disease, non-steroidal anti-inflammatory drugs or glucocorticoid therapy	Shallow breathing with minimal abdominal wall movement, abdominal tenderness and guarding, board-like rigidity, abdominal distension and absent bowel sounds
Acute pancreatitis	Anorexia, nausea, vomiting, constant severe epigastric pain, previous alcohol abuse/cholelithiasis	Fever, periumbilical or loin bruising, epigastric tenderness, variable guarding, reduced or absent bowel sounds
Ruptured aortic aneurysm	Sudden onset of severe, tearing back/loin/abdominal pain, hypotension and past history of vascular disease and/or high blood pressure	Shock and hypotension, pulsatile, tender, abdominal mass, asymmetrical femoral pulses
Acute mesenteric ischaemia	Anorexia, nausea, vomiting, bloody diarrhoea, constant abdominal pain, previous history of vascular disease and/or high blood pressure	Atrial fibrillation, heart failure, asymmetrical peripheral pulses, absent bowel sounds, variable tenderness and guarding
Intestinal obstruction	Colicky central abdominal pain, nausea, vomiting and constipation	Surgical scars, hernias, mass, distension, visible peristalsis, increased bowel sounds
Ruptured ectopic pregnancy	Premenopausal female, delayed or missed menstrual period, hypotension, unilateral iliac fossa pain, pleuritic shoulder-tip pain, ‘prune juice’-like vaginal discharge	Suprapubic tenderness, periumbilical bruising, pain and tenderness on vaginal examination (cervical excitation), swelling/fullness in fornix on vaginal examination
Pelvic inflammatory disease	Sexually active young female, previous history of sexually transmitted infection, recent gynaecological procedure, pregnancy or use of intrauterine contraceptive device, irregular menstruation, dyspareunia, lower or central abdominal pain, backache, pleuritic right upper quadrant pain (Fitz-Hugh–Curtis syndrome)	Fever, vaginal discharge, pelvic peritonitis causing tenderness on rectal examination, right upper quadrant tenderness (perihepatitis), pain/tenderness on vaginal examination (cervical excitation), swelling/fullness in fornix on vaginal examination

Dysphagia

Patients with dysphagia complain that food or drink sticks when they swallow.

Ask about:

• onset: recent or longstanding

• nature: intermittent or progressive

• difficulty swallowing solids, liquids or both

• the level where food is felt to stick

• any regurgitation or reflux of food or fluid

• any associated pain (odynophagia) or heartburn

• any recent weight loss.

• past history of food bolus obstruction

Do not confuse dysphagia with early satiety, the inability to complete a full meal because of premature fullness, or with globus, which is a feeling of a lump in the throat. Globus does not interfere with swallowing and is not related to eating.

Neurological dysphagia resulting from bulbar or pseudobulbar palsy (p. 140) is worse for liquids than solids and may be accompanied by choking, spluttering and fluid regurgitating from the nose.

Neuromuscular dysphagia, or oesophageal dysmotility, presents in middle age, is worse for solids and may be helped by liquids and sitting upright. Achalasia, when the lower oesophageal sphincter fails to relax normally, typically results in dysphagia for both solids and liquids and leads to progressive oesophageal dilatation above the sphincter. Overflow of secretions and food into the respiratory tract may then occur, especially at night when the patient lies down, causing aspiration pneumonia. Oesophageal dysmotility and acid reflux can provoke oesophageal spasms and central chest pain, which may be confused with cardiac pain.

A pharyngeal pouch may cause food to stick or be regurgitated undigested from previous days and may lead to recurrent chest infections due to chronic silent aspiration.

‘Mechanical’ dysphagia is often due to oesophageal stricture but can be caused by external compression. With weight loss, a short history and no reflux symptoms, suspect oesophageal cancer. Longstanding dysphagia without weight loss but accompanied by heartburn is more likely to be due to benign peptic stricture. Eosinophilic oesophagitis is the most common cause of food bolus obstruction and should be considered in younger patients with dysphagia; it is associated with atopy and food allergy. Record the site at which the patient feels the food sticking; although this is not an entirely reliable guide to the site of obstruction. If dysphagia is experienced high in the neck, consider tumours of the pharynx or larynx or extrinsic compression from a mass lesion such as a thyroid goitre.

Nausea and vomiting

Nausea is the sensation of feeling sick. Vomiting is the expulsion of gastric contents via the mouth. Both are associated with pallor, sweating and hyperventilation.

Ask about:

• relation to meals and timing, such as early morning or late evening

• associated symptoms, such as dyspepsia and abdominal pain, and whether they are relieved by vomiting

• whether the vomit is bile-stained (green), blood-stained or faeculent

• associated weight loss

• the patient’s medications.

Nausea and vomiting, particularly with abdominal pain or discomfort, suggest upper gastrointestinal disorders. Dyspepsia causes nausea without vomiting. Peptic ulcers seldom cause painless vomiting unless they are complicated by pyloric stenosis, which causes projectile vomiting of large volumes of gastric content that is not bile-stained. Obstruction distal to the pylorus produces bile-stained vomit. Severe vomiting without significant pain suggests gastric outlet or proximal small bowel obstruction. Faeculent vomiting of small bowel contents (not faeces) is a late feature of distal small bowel or colonic obstruction. In peritonitis, the vomitus is usually small in volume but persistent. The more distal the level of intestinal obstruction, the more marked the accompanying abdominal distension and colic.

Vomiting is common in gastroenteritis, cholecystitis, pancreatitis and hepatitis. It is typically preceded by nausea but raised intracranial pressure may occur without warning. Severe pain may precipitate vomiting, as in renal or biliary colic or myocardial infarction.

Anorexia nervosa and bulimia are eating disorders characterised by undisclosed, self-induced vomiting. In bulimia, weight is maintained or increased, unlike in anorexia nervosa, where profound weight loss is common.

Other non-gastrointestinal causes of nausea and vomiting include:

• drugs, such as opioids, theophyllines, digoxin, cytotoxic agents, antidepressants or alcohol

• pregnancy

• diabetic ketoacidosis

• renal or liver failure

• hypercalcaemia

• Addison’s disease

• raised intracranial pressure (meningitis, brain tumour)

• vestibular disorders (labyrinthitis and Ménière’s disease).

Wind and flatulence

Belching, excessive or offensive flatus, abdominal distension and borborygmi (audible bowel sounds) are often called ‘wind’ or flatulence. Clarify exactly what the patient means. Belching is due to air swallowing (aerophagy) and has no medical significance. It may indicate anxiety but sometimes occurs in an attempt to relieve abdominal pain or discomfort and accompanies GORD.

Normally, 200–2000 mL of flatus is passed each day. Flatus is a mixture of gases derived from swallowed air and colonic bacterial fermentation of poorly absorbed carbohydrates. Excessive flatus occurs particularly in lactase deficiency and intestinal malabsorption.

Borborygmi result from the movement of fluid and gas along the bowel. Loud borborygmi, particularly if associated with colicky discomfort, suggest small bowel obstruction or dysmotility.

Abdominal distension

Abdominal girth slowly increasing over months or years is usually due to obesity but in a patient with weight loss, it suggests intra-abdominal disease. The most common causes of abdominal distension are:

• fat due to obesity

• flatus due to pseudo-obstruction or bowel obstruction

• faeces due to subacute obstruction or constipation

• fluid due to ascites (accumulation of fluid in the peritoneal cavity; Fig. 6.6 ), tumours (especially ovarian) or a distended bladder

  

• fetus

• functional bloating (fluctuating abdominal distension that develops during the day and resolves overnight, usually occurring in irritable bowel syndrome).