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Evaluation of the Gastrointestinal Patient

By

Stephanie M. Moleski

, MD, Sidney Kimmel Medical College at Thomas Jefferson University

Last full review/revision Apr 2021| Content last modified Apr 2021
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Gastrointestinal (GI) symptoms and disorders are quite common. History and physical examination are often adequate to make a disposition in patients with minor complaints; in other cases, testing is necessary.

History

Using open-ended, interview-style questions, the physician identifies the location and quality of symptoms and any aggravating and alleviating factors.

Abdominal pain is a frequent GI complaint (see Acute Abdominal Pain Acute Abdominal Pain Abdominal pain is common and often inconsequential. Acute and severe abdominal pain, however, is almost always a symptom of intra-abdominal disease. It may be the sole indicator of the need... read more and Chronic and Recurrent Abdominal Pain Chronic Abdominal Pain and Recurrent Abdominal Pain Chronic abdominal pain (CAP) is pain that persists for more than 3 months either continuously or intermittently. Intermittent pain may be referred to as recurrent abdominal pain (RAP). Acute... read more ). Determining the location of the pain can help with the diagnosis. For example, pain in the epigastrium may reflect problems in the pancreas, stomach, or small bowel. Pain in the right upper quadrant may reflect problems in the liver, gallbladder, and bile ducts such as cholecystitis Acute Cholecystitis Acute cholecystitis is inflammation of the gallbladder that develops over hours, usually because a gallstone obstructs the cystic duct. Symptoms include right upper quadrant pain and tenderness... read more or hepatitis Causes of Hepatitis Hepatitis is an inflammation of the liver characterized by diffuse or patchy necrosis. Hepatitis may be acute or chronic (usually defined as lasting > 6 months). Most cases of acute viral hepatitis... read more . Pain in the right lower quadrant may indicate inflammation of the appendix, terminal ileum, or cecum, suggesting appendicitis Appendicitis Appendicitis is acute inflammation of the vermiform appendix, typically resulting in abdominal pain, anorexia, and abdominal tenderness. Diagnosis is clinical, often supplemented by CT or ultrasonography... read more Appendicitis , ileitis, or Crohn disease Crohn Disease Crohn disease is a chronic transmural inflammatory bowel disease that usually affects the distal ileum and colon but may occur in any part of the gastrointestinal tract. Symptoms include diarrhea... read more Crohn Disease . Pain in the left lower quadrant may indicate diverticulitis Colonic Diverticulitis Diverticulitis is inflammation with or without infection of a diverticulum, which can result in phlegmon of the bowel wall, peritonitis, perforation, fistula, or abscess. The primary symptom... read more Colonic Diverticulitis or constipation Constipation Constipation is difficult or infrequent passage of stool, hardness of stool, or a feeling of incomplete evacuation. (See also Constipation in Children.) No bodily function is more variable and... read more . Pain in either the left or right lower quadrant may indicate colitis, ileitis, or ovarian (in women) etiologies. (See figure Location of abdominal pain and possible causes Location of abdominal pain and possible causes Gastrointestinal (GI) symptoms and disorders are quite common. History and physical examination are often adequate to make a disposition in patients with minor complaints; in other cases, testing... read more .)

Location of abdominal pain and possible causes

Location of abdominal pain and possible causes

Asking patients about radiation of pain may help clarify the diagnosis. For example, pain radiating to the shoulder may reflect cholecystitis Acute Cholecystitis Acute cholecystitis is inflammation of the gallbladder that develops over hours, usually because a gallstone obstructs the cystic duct. Symptoms include right upper quadrant pain and tenderness... read more because the gallbladder may be irritating the diaphragm. Pain radiating to the back may reflect pancreatitis Overview of Pancreatitis Pancreatitis is classified as either acute or chronic. Acute pancreatitis is inflammation that resolves both clinically and histologically. Chronic pancreatitis is characterized by histologic... read more . Asking patients to describe the character of the pain (ie, sharp and constant, waves of dull pain) and the onset (sudden, such as resulting from a perforated viscus or ruptured ectopic pregnancy) can help differentiate causes.

Patients should be queried about changes in eating and elimination. Regarding eating, patients should be asked about difficulty swallowing (dysphagia Dysphagia Dysphagia is difficulty swallowing. The condition results from impeded transport of liquids, solids, or both from the pharynx to the stomach. Dysphagia should not be confused with globus sensation... read more ), loss of appetite, and presence of nausea and vomiting Nausea and Vomiting Nausea, the unpleasant feeling of needing to vomit, represents awareness of afferent stimuli (including increased parasympathetic tone) to the medullary vomiting center. Vomiting is the forceful... read more . If patients are vomiting, they should be asked how often and for how long and whether they have noted blood or coffee-ground–like material suggestive of GI bleeding Overview of Gastrointestinal Bleeding Gastrointestinal (GI) bleeding can originate anywhere from the mouth to the anus and can be overt or occult. The manifestations depend on the location and rate of bleeding. (See also Varices... read more . Also, patients should be asked about the type and quantity of liquids they have tried to drink, if any, and whether they have been able to keep them down.

Regarding elimination, patients should be asked when their most recent bowel movement was, how frequently they have been having bowel movements, and whether this frequency represents a change from their typical frequency. It is more useful to ask for specific, quantitative information about bowel movements rather than simply asking whether they are constipated or have diarrhea because different people use these terms quite differently. Patients should also be asked to describe the color and consistency of the stool, including whether stool has appeared black or bloody (suggestive of GI bleeding), purulent, or mucoid. Patients who have noticed blood should be asked whether it was coating the stool, mixed with stool, or whether blood was passed without any stool.

Patients report symptoms differently depending on their personality, the impact of the illness on their life, and sociocultural influences. For example, nausea and vomiting may be minimized or reported indirectly by a severely depressed patient but presented with dramatic urgency by a histrionic one.

Important elements of the past medical history include presence of previously diagnosed GI disorders, previous abdominal surgery, and use of drugs and substances that might cause GI symptoms (eg, nonsteroidal anti-inflammatory drugs [NSAIDs], alcohol, marijuana).

Physical Examination

The physical examination might begin with inspection of the oropharynx to assess hydration, ulcers, or possible inflammation.

Inspection of the abdomen with the patient supine may show a convex appearance when bowel obstruction, ascites, or, rarely, a large mass is present. Auscultation to assess bowel sounds and determine presence of bruits should follow. Percussion elicits hyperresonance (tympany) in the presence of bowel obstruction and dullness with ascites and can determine the span of the liver. Palpation proceeds systematically, beginning gently to identify areas of tenderness and, if tolerated, palpating deeper to locate masses or organomegaly.

When the abdomen is tender, patients should be assessed for peritoneal signs such as guarding and rebound. Guarding is an involuntary contraction of the abdominal muscles that is slightly slower and more sustained than the rapid, voluntary flinch exhibited by sensitive or anxious patients. Rebound is a distinct flinch upon brisk withdrawal of the examiner's hand.

Testing

Patients with acute, nonspecific symptoms (eg, dyspepsia, nausea) and an unremarkable physical examination rarely require testing. Findings suggesting significant disease (alarm symptoms) should prompt further evaluation:

  • Anorexia

  • Anemia

  • Blood in stool (gross or occult)

  • Dysphagia

  • Fever

  • Hepatomegaly

  • Pain that awakens patient

  • Persistent nausea and vomiting

  • Weight loss

Chronic or recurrent symptoms, even with an unremarkable examination, also warrant evaluation. See Diagnostic and Therapeutic Gastrointestinal Procedures Diagnostic and Therapeutic Gastrointestinal Procedures read more for specific GI tests.

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