Taking the gastrointestinal history

Taking the gastro-intestinal historyDr. J.A. CoetserDepartment of Internal MedicineCoetserJA@ufs.ac.za

SOCRATES

SiteOnsetCharacterRadiationAlleviating factorsTimingExacerbating factorsSeverityPresenting symptoms:Abdominal painSiteWhere is the maximum intensity of the pain?Parietal peritoneum involvement gives very localized painE.g. appendicitis

Presenting symptoms:Abdominal painOnsetIs pain acute or chronic?When did it begin?How often does it occur?

Presenting symptoms:Abdominal painCharacter and patternColicky or steady?Colicky pain due to peristaltic movementsBowel obstructionUrethers

Presenting symptoms:Abdominal pain

Presenting symptoms:Abdominal painRadiationTo the back = pancreatic disease / peptic ulcerTo the shoulder = diaphragmaticTo the neck = oesophageal reflux

Presenting symptoms:Abdominal painAlleviating factorsAntacids may relieve peptic ulcer or reflux painDefaecation or passing of flatus may relieve pain from colon diseaseRolling around may relieve colicky painLying very still may relieve pain from peritonitis

Presenting symptoms:Abdominal painTimingPain from peptic ulceration may be related to mealsAsk about the daily pattern of pain

Presenting symptoms:Abdominal painExacerbating factorsEating may precipitate ischaemic pain or pancreatic painCoffee, alcohol, spicy food may exacerbate reflux

Presenting symptoms:Abdominal painPattern of peptic ulcer disease pain

Dull or burning epigastric pain Episodic May occur at night, may wake patient Pain often unrelated to meals

Presenting symptoms:Abdominal painPattern of pancreatic painEpigastric painRelieved by sitting up and leaning forwardPain often radiates to backVomiting often associated

Presenting symptoms:Abdominal painPattern of biliary painRarely colickyEpigastric pain with cystic duct obstructionUsually severe, constant for hoursHistory of similar episodes in pastIf cholecystitis develops, pain can shift to right hypochondrium

Presenting symptoms:Abdominal painPattern of renal colic painColicky pain superimposed on background of constant pain in renal angleOften radiates to groin

Presenting symptoms:Abdominal painPattern of bowel obstruction painColicky painIf obstruction is in small bowel, pain often periumbilicalColonic pain can occur anywhereSmall bowel obstruction colic cycles every 2-3 minutesLarge bowel obstruction colic cycles every 10-15 minutesObstruction often associated with vomiting, constipation, and abdominal distensionPresenting symptoms:Appetite and weight changeAnorexia + weight lossConsider malignancyDepression could also be a causeIncreased appetite + weight lossMalabsorption of nutrientsThyrotoxicosisLiver disease may cause disturbance of tastePresenting symptoms:Early satiation and postprandial fullnessEarly satiation can be due to gastric diseasesGastric cancerPeptic ulcerPresenting symptoms:Nausea and vomitingCausesGIT infections, e.g. S.aureusSmall bowel obstructionPregnancyDrugs (digoxin, opiates, dopamine agonists, chemotherapy)Peptic ulcer disease with gastric outlet obstructionGastroparesis from e.g. diabetes mellitusAcute hepatobiliary diseaseAlcoholismPsychogenic vomitingEating disorders e.g. bulimiaRaised intracranial pressure

Presenting symptoms:Nausea and vomitingTiming of vomitingDelayed >1h after meal = gastric outlet obstructionEarly morning vomiting = pregnancy, raised intracranial pressure, alcoholismContents of vomitusBile = connection between stomach and duodenumOld food = gastric outlet obstructionBlood = ulceration

Presenting symptoms:Heartburn and acid regurgitationHeartburnRetrosternal burning pain or discomfort, due to inappropriate relaxation of lower oesophageal sphincterAggravated by bending or lying downRelieved by antacidsAcid regurgitationSour or bitter tasting fluid coming up into mouthWaterbrashExcessive secretion of saliva into mouth, associated with peptic ulcer disease or oesophagitisPresenting symptoms:DysphagiaDysphagia = difficulty in swallowingCan occur with solids or liquidsOdynophagia = painful swallowingCausesInfectious oesophagitisPeptic ulcerationCaustic damage to oesophagusAsk patient to point to site where food gets stuck

Presenting symptoms:DysphagiaDysphagia + heartburn = possible stricture formationDysphagia only with 1st few swallows = lower oesophageal ring / oesophageal spasmProgressive dysphagia for solids = stricture / carcinoma / achalasiaDysphagia for both solids and liquids = motor disorders, e.g. achalasia

Presenting symptoms:DiarrhoeaIncreased frequency of stools (>3 per day)Change in consistency, loose and wateryDistinguish between acute and chronic diarrhoea

Presenting symptoms:DiarrhoeaSecretoryOsmoticAbnormal intestinal motilityExudativeMalabsorptionPresenting symptoms:DiarrhoeaSecretory diarrhoeaHigh volumePersists when patient fastsOccurs when secretion in GIT exceeds absorption, e.g. choleraOsmotic diarrhoeaLarge volume stoolsDisappears with fastingOccurs due to excessive solute drag, e.g. lactose intoleranceAbnormal intestinal motilityE.g. thyrotoxicosis, irritable bowel syndrome

Presenting symptoms:DiarrhoeaExudative diarrhoeaSmall volume stools, but frequentAssociated blood or mucusE.g. inflammatory bowel diseaseMalabsorptionCan result in steatorrhoea = fatty, pale colored, extremely smelly, floating, difficult to flush away>7g fat in 24h stool

Presenting symptoms:ConstipationMay refer to:Frequency