The Gastrointestinal Tract

"How is your appetite?" is a good starting question and may lead into other important areas such as indigestion, nausea, vomiting, and anorexia. Patients often complain of indigestion, a common complaint that refers to distress associated with eating, but patients use the term for many different symptoms. Find out just what your patient means. Possibilities include:

Anorexia, nausea, vomiting in many gastrointestinal disorders; also in pregnancy, diabetic ketoacidosis, adrenal insufficiency, hypercalcemia, uremia, liver disease, emotional states, adverse drug reactions, and other conditions. Induced but without nausea in anorexia/ bulimia.

Heartburn, or a sense of burning or warmth that is retrosternal and may radiate from the epigastrium to the neck. It usually originates in the esophagus. If persistent, especially in the epigastric area, it may raise the question of heart disease. Some patients with coronary artery disease describe their pain as burning, "like indigestion." Pay special attention to what brings on the discomfort and what relieves it. Is it precipitated by exertion and relieved by rest, suggesting angina, or is it related to meals and made worse during or after eating, suggesting gastroesophageal reflux?

Heartburn suggests gastric acid reflux into the esophagus; often precipitated by a heavy meal, lying down, or bending forward, also by ingested alcohol, citrus juices, or aspirin. If chronic, consider reflux esophagitis. See Table 6-1, Chest Pain, pp. 234-235.

Excessive gas, especially with frequent belching, abdominal bloating or distention, or flatus, the passage of gas by rectum, normally about 600 ml per day. Find out if these symptoms are associated with eating specific foods. Ask if symptoms are related to ingestion of milk or milk products.

Belching, but not bloating or excess flatus, normally seen in aerophagia, or swallowing air. Also consider legumes and other gas-producing foods, intestinal lactase deficiency, irritable bowel syndrome.

■ Unpleasant abdominal fullness after meals of normal size, or early satiety, the inability to eat a full meal.

Consider diabetic gastroparesis, anticholinergic drugs, gastric outlet obstruction, gastric cancer; early satiety in hepatitis.

■ Nausea and vomiting

■ Abdominal pain

Anorexia is a loss or lack of appetite. Find out if it arises from intolerance to certain foods or reluctance to eat due to anticipated discomfort. Nausea, often described as "feeling sick to my stomach," may progress to retching or vomiting. Retching describes the spasmodic movements of the chest and diaphragm that precede and culminate in vomiting, the forceful expulsion of gastric contents out through the mouth.

Some patients may not actually vomit but raise esophageal or gastric contents in the absence of nausea or retching, called regurgitation.

Ask about any vomitus or regurgitated material and inspect it yourself if possible. What color is it? What does the vomitus smell like? How much has there been? Ask specifically if it contains any blood and try to determine how much. You may have to help the patient with the amount . . . a teaspoon? Two teaspoons? A cupful?

Gastric juice is clear or mucoid. Small amounts of yellowish or greenish bile are common and have no special significance. Brownish or blackish vomitus with a "coffee-grounds" appearance suggests blood altered by gastric acid. Coffee-grounds emesis or red blood are termed hematemesis.

Do the patient's symptoms suggest any complications of vomiting such as aspiration into the lungs, seen in elderly, debilitated, or obtunded patients? Is there dehydration or electrolyte imbalance from prolonged vomiting, or significant loss of blood?

Abdominal pain has several possible mechanisms and clinical patterns and warrants careful clinical assessment. Be familiar with three broad categories of abdominal pain:

■ Visceral pain occurs when hollow abdominal organs such as the intestine or biliary tree contract unusually forcefully or when they are distended or stretched. Solid organs such as the liver can also become painful when their capsules are stretched. Visceral pain may be difficult to localize. It is typically, though not necessarily, palpable near the midline, at levels that vary according to the structure involved, as illustrated on the next page.

Visceral pain varies in quality and may be gnawing, burning, cramping, or aching. When it becomes severe, it may be associated with sweating, pallor, nausea, vomiting, and restlessness.

■ Parietal pain originates in the parietal peritoneum and is caused by inflammation. It is a steady aching pain that is usually more severe than visceral pain and more precisely localized over the involved structure. It is typically aggravated by movement or coughing. Patients with this type of pain usually prefer to lie still.

Anorexia, nausea, vomiting in many gastrointestinal disorders; also in pregnancy, diabetic ketoacidosis, adrenal insufficiency, hypercalcemia, uremia, liver disease, emotional states, adverse drug reactions. Induced but without nausea in anorexia/bulimia nervosa.

Regurgitation in esophageal narrowing from stricture or cancer; also with incompetent gastroesophageal sphincter

Fecal odor in small bowel obstruction or gastrocolic fistula

Hematemesis in duodenal or peptic ulcer, esophageal or gastric varices, gastritis

Symptoms of blood loss such as light-headedness or syncope depend on the rate and volume of bleeding, and rarely appear until blood loss > 500 ml.

See Table 9-1, Abdominal Pain (pp. 350-351).

Visceral pain in the right upper quadrant from liver distention against its capsule in alcoholic hepatitis

Visceral periumbilical pain in early acute appendicitis from distention of inflamed appendix, gradually changing to parietal pain in the right lower quadrant from inflammation of the adjacent parietal peritoneum

Right upper quadrant or epigastric pain from the biliary tree and liver

Suprapubic or sacral pain from the rectum

Suprapubic or sacral pain from the rectum

Pain Intestine And Bladder Fistula

Epigastric pain from the stomach, duodenum, or pancreas

Periumbilical pain from the small intestine, appendix, or proximal colon

Hypogastric pain from the colon, bladder, or uterus. Colonic pain may be more diffuse than illustrated.

Epigastric pain from the stomach, duodenum, or pancreas

Periumbilical pain from the small intestine, appendix, or proximal colon

Hypogastric pain from the colon, bladder, or uterus. Colonic pain may be more diffuse than illustrated.

■ Referred pain is felt in more distant sites, which are innervated at approximately the same spinal levels as the disordered structure. Referred pain often develops as the initial pain becomes more intense and thus seems to radiate or travel from the initial site. It may be felt superficially or deeply but is usually well localized.

Pain may also be referred to the abdomen from the chest, spine, or pelvis, thus complicating the assessment of abdominal pain.

Ask patients to describe the abdominal pain in their own words, then ask them to point to the pain. If clothes interfere, repeat the question during the physical examination. You may need to pursue important details: "Where does the pain start?" "Does it radiate or travel anywhere?" "What is the pain like?" If the patient has trouble describing the pain, try a multiple-choice question such as "Is it aching, burning, gnawing, or what?"

You need to ask "How severe is the pain?" "How about on a scale of 1 to 10?" Find out if it is bearable and if it interferes with the patient's usual activities. Does it make the patient lie down?

The description of the severity of the pain may tell you something about the patient's responses to pain and its impact on the patient's life, but it is not consistently helpful in assessing the pain's cause. Sensitivity to abdominal pain varies widely and tends to diminish over the later years, masking acute abdominal problems in older people, especially those in or beyond their 70s.

Pain of duodenal or pancreatic origin may be referred to the back; pain from the biliary tree, to the right shoulder or the right posterior chest.

Pain from pleurisy or acute myocardial infarction may be referred to the upper abdomen.

Cramping colicky pain often is related to peristalsis.

Careful timing of the pain, on the other hand, is particularly helpful. Did it start suddenly or gradually? When did the pain begin? How long does it last? What is its pattern over a 24-hour period? Over weeks and months? Are you dealing with an acute illness or a chronic or recurring one?

Determine what factors aggravate or relieve the pain, with special reference to meals, antacids, alcohol, medications (including aspirin and aspirinlike drugs and any over-the-counter drugs), emotional factors, and body position. Also, is the pain related to defecation, urination, or menstruation? You also need to elicit any symptoms that are associated with the pain, such as fever or chills, and ask in what sequence they occur.

Citrus fruits may aggravate the pain of reflux esophagitis; possible lactase deficiency if abdominal discomfort from milk ingestion

Less commonly, patients may report difficulty swallowing, or dysphagia, the sense that food or liquid is sticking, hesitating, or "won't go down right." Dysphagia may result from esophageal disorders or from difficulty transferring food from the mouth to the esophagus. The sensation of a lump in the throat or in the retrosternal area, unassociated with swallowing, is not true dysphagia.

For types of dysphagia, see Table 9-2, Dysphagia, p. 352.

Ask the patient to point to where the dysphagia occurs and describe with what types of food. Does it occur with relatively solid foods such as meat, with softer foods such as ground meat and mashed potatoes, or with hot or cold liquids? Has the pattern changed?

Pointing to the throat suggests a transfer or esophageal disorder; pointing to the chest suggests an esophageal disorder.

Establish the timing. When did it start? Is it intermittent or persistent? Is it progressing? If so, over what period of time? What are the associated symptoms and medical conditions?

Dysphagia with solid food in mechanical narrowing of the esophagus; dysphagia related to both solids and liquids suggests a disorder of esophageal motility.

Odynophagia, or pain on swallowing, may occur in two forms. A sharp, burning pain suggests mucosal inflammation, while a squeezing, cramping pain suggests a muscular cause. Odynophagia may accompany dysphagia, but either symptom may occur independently.

Mucosal inflammation in reflux esophagitis or infection from Candida, herpesvirus, or cytomegalovirus.

With respect to the lower gastrointestinal tract, you will frequently need to assess bowel function. Start with open-ended questions: "How are your bowel movements?" "How frequent are they?" "Do you have any difficulties?" "Have you noticed any change in your bowel habits?" Frequency of bowel movements normally ranges from about three times a day to twice a week. A change in pattern within these limits, however, may be significant for an individual patient.

Patients vary widely in their views of constipation and diarrhea. Be sure to clarify what the patient means by these terms. For example, is constipation . . . a decrease in frequency of bowel movements? . . . The passage of hard and perhaps painful stools? . . . The need to strain unusually hard? . . . A sense of incomplete defecation or pressure in the rectum? Ask if the patient actually looks at the stool. If yes, what does the stool look like in terms of color and bulk? What remedies has the patient tried? Do medications, stress, unrealistic ideas

See Table 9-3, Constipation (p. 353).

Thin pencil-like stool in an obstructing "apple-core" lesion of the sigmoid colon about normal bowel habits, or time and setting allotted for defecation play a role? Occasionally there is complete constipation with no passage of either feces or gas, or obstipation.

Inquire about the color of the stools and ask about any black tarry stools, suggesting melena, or red blood in the stools, known as hematochezia. If either condition is present, find out how long and how often. If the blood is red, how much is there? Is it pure blood mixed in with stool or on the surface of the stool? Is there blood on the toilet paper?

Diarrhea is an excessive frequency in the passage of stools that are usually unformed or watery. Ask about size, frequency, and volume. Are the stools bulky or small? How many episodes of diarrhea occur each day?

Ask for descriptive terms. Are the stools greasy or oily? Frothy? Foul smelling? Floating on the surface because of excessive gas, making them difficult to flush? Accompanied by mucus, pus, or blood?

Assess the course of diarrhea over time. Is it acute, chronic, or recurrent? Or is your patient experiencing the first acute episode of a chronic or recurrent illness?

Look into other factors as well. Does the diarrhea awaken the patient at night? What seem to be the aggravating or relieving factors? Does the patient get relief from a bowel movement, or is there an intense urge with straining but little or no result, known as tenesmus. What is the setting? Does it entail travel, stress, or a new medication? Do family members or companions have similar symptoms? Are there associated symptoms?

In some patients, you will be struck by jaundice or icterus, the yellowish discoloration of the skin and sclerae from increased levels of bilirubin, a bile pigment derived chiefly from the breakdown of hemoglobin. Normally the hepatocytes conjugate, or combine, unconjugated bilirubin with other substances, making the bile water soluble, and then excrete it into the bile. The bile passes through the cystic duct into the common bile duct, which also drains the extrahepatic ducts from the liver. More distally the common bile duct and the pancreatic ducts empty into the duodenum at the ampulla of Vater. Mechanisms of jaundice include:

■ Increased production of bilirubin

■ Decreased uptake of bilirubin by the hepatocytes

■ Decreased ability of the liver to conjugate bilirubin

Obstipation in intestinal obstruction

See Table 9-5, Black and Bloody Stools, p. 356.

Blood on the stool surface and on toilet paper in hemorrhoids

Consistently large diarrheal stools often in small bowel or proximal colon disorders; small frequent stools with urgency of defecation in left colon or rectal disorders

Large yellowish or gray greasy foul smelling, sometimes frothy or floating stools in steatorrhea, or fatty stools—seen in malabsorption

Nocturnal diarrhea suggests a pathophysiologic cause.

Relief after passing feces or gas suggests left colon or rectal disorders; tenesmus in rectal conditions near the anal sphincter

Predominantly unconjugated bilirubin from the first three mechanisms, as in hemolytic anemia (increased production) and Gilbert's syndrome

■ Decreased excretion of bilirubin into the bile, resulting in absorption of conjugated bilirubin back into the blood.

Intrahepatic jaundice can be hepatocellular, from damage to the hepato-cytes, or cholestatic, from impaired excretion due to damaged hepatocytes or intrahepatic bile ducts. Extrahepatic jaundice arises from obstruction of the extrahepatic bile ducts, most commonly the cystic and common bile ducts.

As you assess the jaundiced patient, pay special attention to the associated symptoms and the setting in which the illness occurred. What was the color ofthe urine as the patient became ill? When the level of conjugated bilirubin increases in the blood, it may be excreted into the urine, turning the urine a dark yellowish brown or tea color. Unconjugated bilirubin is not water-soluble so is not excreted into urine.

Ask also about the color of the stools. When excretion of bile into the intestine is completely obstructed, the stools become gray or light-colored, or acholic, without bile.

Does the skin itch without other obvious explanation? Is there associated pain? What is its pattern? Has it been recurrent in the past?

Are there risk factors for liver diseases such as:

■ Hepatitis: Travel or meals in areas of poor sanitation, ingestion of contaminated water or foodstuffs (hepatitis A); parenteral or mucous membrane exposure to infectious body fluids such as blood, serum, semen, and saliva, especially through sexual contact with an infected partner or use of shared needles for injection drug use (hepatitis B); intravenous illicit drug use or blood transfusion (hepatitis C)

■ Alcoholic hepatitis or alcoholic cirrhosis (interview the patient carefully about alcohol use)

■ Toxic liver damage from medications, industrial solvents, or environmental toxins

Gallbladder disease or surgery that may result in extrahepatic biliary obstruction

■ Hereditary disorders in the Family History

Impaired excretion of conjugated bilirubin in viral hepatitis, cirrhosis, primary biliary cirrhosis, drug-induced cholestasis, as with oral contraceptives, methyl testosterone, chlorpromazine

Obstruction of the common bile duct by gallstones or pancreatic carcinoma

Dark urine from bilirubin indicates impaired excretion of bilirubin into the gastrointestinal tract.

Acholic stools briefly in viral hepatitis, common in obstructive jaundice

Itching in cholestatic or obstructive jaundice; pain from a distended liver capsule, biliary cholic, pancreatic cancer

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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Responses

  • Allie
    Where is pancreas pain?
    7 years ago
  • Nile
    Where is periumbilical pain?
    7 years ago
  • Yusef
    What causes fistulas on the lower abdomen?
    7 years ago
  • Filip Sutherland
    Where Is Bladder Pain?
    7 years ago
  • ross
    How does appendix pain start?
    7 years ago
  • yorda
    Where is pancreas pain felt?
    7 years ago
  • doderic
    Where it pains if pancreatic?
    4 years ago
  • magnus
    Where is the pain for pancreatic cancer?
    3 years ago

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