Transcript Taking the gastrointestinal history

Dr. J.A. Coetser
Department of Internal Medicine
[email protected]
 Site
 Onset
 Character
 Radiation
 Alleviating
factors
 Timing
 Exacerbating
 Severity
factors
 Site
• Where is the maximum intensity of the pain?
• Parietal peritoneum involvement gives very
localized pain
• E.g. appendicitis
 Onset
• Is pain acute or chronic?
• When did it begin?
• How often does it occur?
 Character
and pattern
• Colicky or steady?
• Colicky pain due to peristaltic movements
 Bowel obstruction
 Urethers
 Radiation
 To the back = pancreatic disease / peptic ulcer
 To the shoulder = diaphragmatic
 To the neck = oesophageal reflux
 Alleviating
factors
• Antacids may relieve peptic ulcer or reflux pain
• Defaecation or passing of flatus may relieve pain
from colon disease
• Rolling around may relieve colicky pain
• Lying very still may relieve pain from peritonitis
 Timing
• Pain from peptic ulceration may be related to
meals
• Ask about the daily pattern of pain
 Exacerbating
factors
• Eating may precipitate ischaemic pain or
pancreatic pain
• Coffee, alcohol, spicy food may exacerbate
reflux
 Pattern
of peptic ulcer disease pain
 Pattern
of pancreatic pain
• Epigastric pain
• Relieved by sitting up and leaning forward
• Pain often radiates to back
• Vomiting often associated
 Pattern
of biliary pain
• Rarely colicky
• Epigastric pain with
cystic duct obstruction
• Usually severe, constant
for hours
• History of similar
episodes in past
• If cholecystitis develops,
pain can shift to right
hypochondrium
 Pattern
of renal colic pain
• Colicky pain superimposed
on background of constant
pain in renal angle
• Often radiates to groin
 Pattern of bowel obstruction pain
• Colicky pain
• If obstruction is in small bowel, pain often
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•
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periumbilical
Colonic pain can occur anywhere
Small bowel obstruction colic cycles every 2-3
minutes
Large bowel obstruction colic cycles every 10-15
minutes
Obstruction often associated with vomiting,
constipation, and abdominal distension
 Anorexia
+ weight loss
• Consider malignancy
• Depression could also be a cause
 Increased
appetite + weight loss
• Malabsorption of nutrients
• Thyrotoxicosis
 Liver
taste
disease may cause disturbance of
 Early
satiation can be due to gastric
diseases
• Gastric cancer
• Peptic ulcer

Causes
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GIT infections, e.g. S.aureus
Small bowel obstruction
Pregnancy
Drugs (digoxin, opiates, dopamine agonists,
chemotherapy)
Peptic ulcer disease with gastric outlet obstruction
Gastroparesis from e.g. diabetes mellitus
Acute hepatobiliary disease
Alcoholism
Psychogenic vomiting
Eating disorders e.g. bulimia
Raised intracranial pressure
 Timing of vomiting
• Delayed >1h after meal = gastric outlet
obstruction
• Early morning vomiting = pregnancy, raised
intracranial pressure, alcoholism
 Contents of vomitus
• Bile = connection between stomach and
duodenum
• Old food =
gastric outlet obstruction
• Blood = ulceration
 Heartburn
• Retrosternal burning pain or discomfort, due to
inappropriate relaxation of lower oesophageal
sphincter
• Aggravated by bending or lying down
• Relieved by antacids
 Acid regurgitation
• Sour or bitter tasting fluid coming up into mouth
 Waterbrash
• Excessive secretion of saliva into mouth,
associated with peptic ulcer disease or
oesophagitis
 Dysphagia
= difficulty in swallowing
• Can occur with solids or liquids
 Odynophagia
= painful swallowing
• Causes
 Infectious oesophagitis
 Peptic ulceration
 Caustic damage to oesophagus
 Ask
patient to point to site where food
gets stuck
 Dysphagia
+ heartburn = possible
stricture formation
 Dysphagia only with 1st few swallows =
lower oesophageal ring / oesophageal
spasm
 Progressive dysphagia for solids =
stricture / carcinoma / achalasia
 Dysphagia for both solids and liquids =
motor disorders, e.g. achalasia
 Increased
frequency of stools (>3 per
day)
 Change in consistency, loose and watery
 Distinguish between acute and chronic
diarrhoea
 Secretory
 Osmotic
 Abnormal
intestinal motility
 Exudative
 Malabsorption
 Secretory diarrhoea
• High volume
• Persists when patient fasts
• Occurs when secretion in GIT exceeds absorption,
e.g. cholera
 Osmotic diarrhoea
• Large volume stools
• Disappears with fasting
• Occurs due to excessive solute drag, e.g. lactose
intolerance
 Abnormal intestinal motility
• E.g. thyrotoxicosis, irritable bowel syndrome
 Exudative
diarrhoea
• Small volume stools, but frequent
• Associated blood or mucus
• E.g. inflammatory bowel disease
 Malabsorption
• Can result in steatorrhoea = fatty, pale colored,
extremely smelly, floating, difficult to flush away
• >7g fat in 24h stool
 May refer to:
• Frequency <3/week
• Hard consistency
• Straining to evacuate stools
 Causes:
• Drugs
• Metabolic
• Endocrine
• Neurological
• Malignancy
• Pregnancy
• Perineal problems
 Irritable bowel syndrome
• Can present with alternating constipation and
diarrhoea
• No structural or biochemical abnormality
• Abdominal pain plus 2 or more:
 Pain relieved by defecation
 Looser or more frequent stools with onset of
abdominal pain
 Mucus per rectum
 Feeling of incomplete emptying of rectum
 Visible abdominal distension
 Solitary
rectal ulcer
 Fistula
 Villous
adenoma
 Irritable bowel syndrome
 Haematemesis
• Vomiting of blood (coffee-ground vomitus)
• Ensure this is not from a nose bleed, bleeding
tooth socket or coughing up of blood
• Usually from source
proximal to or at duodenum
• E.g. peptic ulcer disease
• Mallory-Weiss tear
due to repeated vomiting
 Haematochezia
• Bright red blood per rectum
• Blood usually not mixed with stool, found in toilet
bowl
• E.g. haemorrhoids, local anorectal diseases
 Melaena
stools
• Black, offensive, tarry stools
• Bleeding from upper GIT
 Massive
rectal bleeding
• From distal colon or rectum
• Angiodysplasia
• Diverticular disease
 Angiodysplasia
 Diverticular
disease
 Excess
bilirubin deposited in skin and
sclerae
 Ask about colour of urine and stools
• If pale stools and dark urine = obstructive or
cholestatic jaundice
• Stercobilinogen unable to reach intestine
 Ask
about abdominal pain
• Gallstones can cause biliary pain
 Pruritis
• Itching of skin
• Cholestatic liver disease often causes pruritis, worse
over limbs
 Abdominal
bloating and swelling
• Bloating due to excess gas or irritable bowel
syndrome
• Persistent swelling due to ascites
 Lethargy
• Chronic liver disease
• Anaemia
 Drugs
indicated in GIT disease:
• NSAIDs = peptic ulcer disease
• Anticholinergic drugs = constipation
• Isoniazid = drug hepatitis
• Rifampicin = drug cholestasis
• Anabolic steroids or contraceptives =
cholestasis / peliosis hepatis
• Paracetamol = liver necrosis
 Surgical
procedures can result in
jaundice
• Anaesthesia e.g. halothane
• Hypoxaemia of liver cells causing ischaemic
hepatitis
• Damage to bile duct during surgery
 History
of relapsing and remitting
epigastric pain, now with acute abdomen
= perforated peptic ulcer
 Past history of inflammatory bowel
disease
 Occupation, e.g. exposure
to hepatitis
 Toxin exposure, e.g. vinyl chloride
 Travel history
 Alcohol history
 Contact with someone who had jaundice
 Sexual history
 Injections, e.g. intravenous drugs,
transfusions, dental treatment, tattooing
 Colon
cancer and familial polyps
 Inflammatory bowel disease
 Coeliac disease