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GASTROINTESTINAL HISTORY

PRESENTING SYMPTOMS:
- ABDOMINAL PAIN: Acute or chronic?
How often? Daily pattern?
- Point to where it hurts:

Irritation of the Diaphragm,


THUS
- Liver
- Gallbladder
Duodenum, - Duodenum
head of pancreas
Stomach
Gallbladder Gallbladder
Spleen
Liver
Small Intestine Liver
Appendix
Caecum and ascending colon Sigmoid colon
Kidney and ureter

ABDOMINAL DISTENTION RADIATING?


Localised = ? parietal peritoneal inflammation
The 7 Fs:
- FAT
- FLUID COLICKY OR STEADY?
Colicky = gut or ureter obstruction
- FOETUS
FLATUS AGGRAVATING FACTORS:
- FAECES After meals: ulcer or ischaemic gut
FILTHY BIG TUMOUR
- PHANTOM PREGNANCY RELIEVING FACTORS:
Vomiting = ulcer or reflux
APPETITE and WEIGHT CHANGE Antacids = ulcer or reflux
Defecation = colonic disease
APPETITE Writhing / rolling = colicky pain
Loss Gain Staying perfectly still = peritonitis
Loss Malignancy Thyrotoxicosis Sitting + leaning forward = pancreatic
Depression MALABSORPTION
WEIGHT
LIVER DISEASE
lots of other stuff PATTERN:
Hypothyroid Cushings Peptic = dull, burning, epigastric
Gain episodic, waking at night
Hypoglycaemia
Hypothalamic disease
* Hepatitis causes smoking cessation Bilious = epigastric, severe, constant
?? HOW MUCH WEIGHT LOSS OVER WHAT PERIOD ??
Pancreatic = constant, vomit-inducing,
NAUSEA +/- VOMITING radiating to back, relieved by
TIMING IS EVERYTHING: sitting +leaning forward
Eg. 1 hour after meal = gastric outlet obstruction
Acute with retching = ? small bowel obstruction
= ? infection
Renal = colic on a background of
Chronic = rule out PREGNANCY and DRUGS constant renal angle pain,
EARLY MORING VOMITING could be radiating to groin
pregnancy, alcoholism or
!! increased intracranial pressure !! Bowel = colicky;
Umbilical every 2-3 min if small bowel,
 CONSIDER ALSO… Anywhere every 10-15 min if large bowel
* Peptic ulcer with gastric outlet obstruction ++ distention, vomiting, constipation
* Gastroparesis after surgery
* acute hepatobiliary disease
* Bulimia nervosa
* psychogenic vomiting

 CONTENTS? Eg. bile, old food, faeces?


REFLUX is aggravated by: HEARTBURN + INDIGESTION:
- Alcohol Typically: burning retrosternal pain radiating to neck
- Chocolate Relieved by antacids
- Caffeine Aggravated by stooping and lying down
- Fatty meal Worse after meals
- Theophylline
- Anticholinergic drugs WATERBRASH: = uncommon = excess saliva secretion
- Calcium channel blockers = symptom of peptic ulcer or oesophagitis
-

DIARRHOEA: DYSPHAGIA + ODYNOPHAGIA:


= Difficult vs. Painful swallowing;
MUST FIND OUT WHICH IT IS!!
FIRST: what do they mean by  When swallowing is PAINFUL there’s inflammation somewhere:
“diarrhoea”? - eg. oesophagitis,
= small but frequent passing of formed - oesophageal perforation,
stool does not make diarrhoea - peptic ulcer of the oesophagus
= local rectal or psychological disturbance  when swallowing is DIFFICULT TO INITIATE and results in
WATER GOING UP THE NOSE
SECOND: is it ACUTE or CHRONIC? and all kinds of CHOKING
Acute = infective = means it’s a PHARYNX ISSUE
Chronic = any damn thing = do neuro exam of CN 9, 10, 12

SORTING BY PATHOLOGY: !! TIMING IS ALL-IMPORTANT !!


SECRETORY  INTERMITTENT with first few swallows being the worst =
- High volume = lower oesophageal ring or oesophageal spasm
- PERSISTS WITH FASTING  CHRONIC PROGRESSIVE =
- No pus, no blood, not fatty = carcinoma, achalasia, or stricture.
- Staph A, E. Coli, V. Cholerae, VIPoma,  BOTH SOLIDS AND LIQUIDS STICK IN THE THROAT?
or gastrin-secreting tumour (Zollinger- = motor disorder more likely eg. achalasia or diffuse spasm
Ellison syndrome), or villous adenoma
 Can the patient localise the area of blockage?
OSMOTIC Is it accompanied by heartburn? = stricture
- DISAPPEARS WITH FASTING
- Large volume, related to meals
- Lactose intolerance, gastric surgery, or -
CONSTIPATION:
magnesium antacids What exactly do they mean?
= infrequent , more solid, or more difficult to excrete?
MALABSORPTIVE - Acute or chronic?
- Classic STEATORRHOEA: - Most often due to habitual neglect of defecation impulse
- Pale , stinking, unflusheable
fat-filled (over 7 grams per 24hrs)
- CONSTIPATION DRUGS:
- NUMEROUS CAUSES
- opiates,
ABNORMAL MOTILITY - antidepressants,
- Thyrotoxicosis - aluminium or calcium antacids
- Irritable bowel syndrome
- Due to Metabolic or Endocrine disease:
EXUDATIVE - Hypothyroidism,
- Small volume - Hypercalcaemia
- Frequent - Diabetes mellitus
- Blood and mucus!! - phaeochromocytoma
- = inflammatory bowel disease - porphyria
- = colon cancer - hypokalemia
- NEURO DISORDERS eg.
IRRITABLE BOWEL SYNDROME: - Agangliosis
Alternating diarrhoea and constipation - Hirschsprung’s disease
… Abdominal pain … - Autonomic neuropathy of diabetes
PLUS 2 or more of the following: - Spinal cord injury
- Abdo pain relieved by defaecation - Multiple sclerosis
- Looser or more frequent stools with the pain
- Mucus in rectum
- Feeling of incomplete emptying - Due to OBSTRUCTION: by faeces, malignancy, etc.
- Visible distension of abdomen
BLEEDING IN THE GIT: !! ASK ABOUT THE DRUGS !! Warfarin, Aspirin, etc
Gotta find the cause for the puncture / ulcer / coagulopathy

HEMATEMESIS MELENA HEMATOCHEZIA


! make sure its from the GUT !! Upper GI bleed passing
not tooth socket or nose through whole of GIT Bright red blood per rectum,
= blood must be coming from = jet black stool, foul stench not mixed with faeces: =
the duodenum up HAEMORRHOIDS
= could also be ingestion of (portosystemic shunt  rectum)
“coffee grounds” = charcoal, liquorice, iron tablets or
stomach contents, slow bleed bismuth- BUT NOTHING IF MIXED WITH FAECES =
SMELLS AS BAD AS BLOOD = MUST BE COLON !!
Frank Red: Varices
(oesophageal portosystemic shunting) JAUNDICE
- The eyes are first to go.
Mallory-Weiss tear:
- after repeated vomiting; ASK ABOUT THE COLOUR OF URINE AND STOOL:
- first clear gastric contents,
- then great volumes of blood JAUNDICE WITHOUT DARK URINE OR PALE STOOL
means HAEMOLYSIS (unconjugated bilirubin released @
circulation, thus not water soluble and cannot be excreted by
kidneys)

JAUNDICE WITH DARK URINE AND PALE STOOLS means


OBSTRUCTIVE JAUNDICE

With PRURITIS: “itchy jaundice”


= biliary obstruction (bile salts cause itching)

With ASCITES (  shifting dullness )


= look for portal hypertension signs / symptoms

MEDICATIONS: want to know about … ALCOHOL, mainly


- NSAIDs  GI bleed
- Halothane
- Phenytoin Acute Hepatitis
- Chlorothiazide
- chlorpromazine
- sulphponamides
sulphonylureas
-
- phenylbutazone
Cholestasis
- rifampicin
- nitrofurantoin
- anabolic steroids
- oral contraceptive
- ALCOHOL
- tetracycline
- valproic acid Steatosis (Fatty Liver )
- amiodarone
- paracetamol Fulminant Necrotic Hepatitis
Allergies:
lactose intolerance, phenylketonuria or gluten restriction may be described as allergies by the patient
PAST HISTORY
!! SURGERY !!
- might have directly damaged the bile duct
- might have had a length of GUT REMOVED
- ANAESTHESIA causes JAUNDICE (i.e halothane)
PAST HISTORY OF INFLAMMATORY BOWEL DISEASE
PAST HISTORY OF HYPERSENSITIVITY TO FOODS

FAMILY HISTORY
- Inflammatory bowel disease
- Anaemia
- splenectomy
- Liver disease, particularly HEPATITIS
- Anybody in the family suffering from the same complaint?
-

SOCIAL HISTORY
- smoking, drugs and alcohol
- AMOUNT IS VERY IMPORTANT
- !! INTRAVENOUS DRUGS ARE VERY IMPORTANT !!
- ?? CONTACT WITH A YELLOW JAUNDICED PERSON ??
- RECENT TRAVEL
- SEXUAL LIASONS
- Blood transfusions, tattoos, dental treatment, basically anything invasive

Occupational History:
!! HEALTH CARE WORKERS !! Ask about NEEDLE STICK INJURIES
- Toxin Exposures:
- carbon tetrachloride, vinyl chloride (textile/dye manufacture)
(chronic liver disease)