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 in the GI Patient
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 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 , 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 . 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 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
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.
A gynecologic history History Most women, particularly those seeking general preventive care, require a complete history and physical examination as well as a gynecologic evaluation. Gynecologic evaluation may be necessary... read more is important in women because gynecologic and obstetric disorders may manifest with GI symptoms.
Associated nonspecific symptoms, such as fever Fever Fever is an elevated body temperature that occurs when the body's thermostat (located in the hypothalamus) resets at a higher temperature, primarily in response to an infection. Elevated body... read more or weight loss Involuntary Weight Loss Involuntary weight loss generally develops over weeks or months. It can be a sign of a significant physical or mental disorder and is associated with an increased risk for mortality. The causative... read more , must be assessed. Unintentional weight loss is an associated symptom that may indicate a more severe problem such as cancer, and the clinician should be prompted to do a more extensive evaluation.
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 patient with severe depression but presented with urgency by a patient who is anxious.
Important elements of the past medical history include presence of previously diagnosed GI disorders, previous abdominal surgery, and use of medications and substances that might cause GI symptoms (eg, nonsteroidal anti-inflammatory drugs [NSAIDs], alcohol).
Physical Examination of the GI Patient
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.
The inguinal area and all surgical scars should be palpated for hernias Hernias of the Abdominal Wall A hernia of the abdominal wall is a protrusion of the abdominal contents through an acquired or congenital area of weakness or defect in the wall. Many hernias are asymptomatic, but some become... read more .
Digital rectal examination (see Evaluation of Anorectal Disorders Physical examination The anal canal begins at the anal verge and ends at the anorectal junction (pectinate line, mucocutaneous junction, dentate line), where there are 8 to 12 anal crypts and 5 to 8 papillae. The... read more ) with testing for occult blood and (in women) pelvic examination Physical Examination Most women, particularly those seeking general preventive care, require a complete history and physical examination as well as a gynecologic evaluation. Gynecologic evaluation may be necessary... read more complete the evaluation of the abdomen.
Testing in the GI Patient
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:
Blood in stool (gross or occult)
Pain that awakens patient from sleep
Persistent nausea and vomiting
Chronic or recurrent symptoms, even with an unremarkable examination, also warrant evaluation. See Diagnostic and Therapeutic GI Procedures Ambulatory pH Monitoring Ambulatory 24-hour esophageal pH monitoring with or without intraluminal impedance testing is currently the most common test for quantifying gastroesophageal reflux (see the American College... read more for specific GI tests.