Gastrointestinal History and Examination

The gastrointestinal tract extends from the lips to the anus and includes the liver, biliary system and pancreas although for the purpose of this article consideration will start at the oesophagus as problems with dentition or with salivary gland disorders and tumours are covered elsewhere.

Ask open questions and give the patient time to elaborate but it is very important to ascertain that you are speaking the same language. Avoid technical terms, jargon or abbreviations. Make sure that you understand what the patient means and get amplification of specific points. To patients the word "stomach" can mean anywhere from the diaphragm to the groin and includes the genitals. "Do you have a hard stool?" may make the patient wonder if the chair in the kitchen is comfortable. Does "coughing up blood" mean haemoptysis or haematemesis? Patients often describe pain as "chronic" meaning severe rather than of long-standing duration.

The following are important aspects of the history that require clarification:

Dysphagia

• What does difficulty in swallowing mean? Dysphagia has many components.
  • Is there pain?
  • Is there a feeling of obstruction?
  • Is food regurgitated? If so, how long after swallowing?
  • Is it a burning pain just after eating?
  • If there is complaint of obstruction ask the patient to point to the level. The obstruction is usually at that level or below.
  • Globus hystericus is usually accompanied by a rather theatrical performance and unlike neurological disorders, the patient denies being able to swallow anything but does not drown in her own saliva and often has not lost weight.
• Oesophageal strictures, webs and rings, gastro-oesophageal reflux disease and oesophageal carcinoma are covered in their own articles.
• Flatulence, wind and bloating are often caused by aerophagy (swallowing air) or a diet too rich in fibre.

Abdominal pain

If there is complaint of abdominal pain ask the patient to point to the location of the pain.

• Does the patient use a single finger or spread the fingers and move the palm over much of the abdomen?
• What is the nature of the pain? Note body language. A burning pain is often described with an open hand move upwards but a clenched fist is used to describe colic.
• Are there any aggravating or relieving factors? The former may include fatty food. The latter may include sitting forward or taking medication.
• How often is the pain and how long does it last?
• Is there radiation elsewhere?

Do not accept such terms as "indigestion" without clarification of exactly what the symptoms are. "Indigestion" aggravated or induced by exercise and relieved by rest is probably angina pectoris.

Bowel function

It is very easy for the doctor and patient to misunderstand each other on this subject.

• Rather than asking if bowels are normal, as normal is such a variable parameter, enquire about any change in bowel habit and its duration.
• Do not accept words such as constipation or diarrhoea without further enquiry. What does the patient mean?
  • How often?
  • What is the consistency?
  • Is there any urgency or faecal incontinence?
  • Is defaecation painful (dyschezia)? Is there tenesmus?
• Is there blood or mucus (call it slime to the patient) in the stool?
  • If there is blood is it always there or just occasionally?
  • Is it mixed in with the stool or separate and splashes the pan? This will help indicate if the bleeding is from low down or higher up.
• What is the colour of the motion?
  • Melaena is black, sticky and tarry and results from a significant high gastrointestinal bleed.
  • Steatorrhoea is pale, bulky, very offensive in smell and is often frothy, floats and takes several attempts to flush away. This indicates gastrointestinal malabsorption of fats.

The Bristol stool chart may help.^1,2

Systematic enquiry

This is especially important in this field.

• Is appetite good?
• Has it changed?
• Is there any change of weight up or down?
  • If so is this intentional? Distinguish dieting from abnormal weight loss.
  • How much over what period of time?
  • Not everyone watches their weight. Are waistbands any tighter or looser than before? Loss of weight means malnutrition.
  • Weight gain and expansion will accompany an enlarging abdominal mass or ascites.
• When seeing females between about 12 and 50 years old record the date of the last menstrual period. Failure to do so with subsequent failure to diagnose a mass arising from the pelvis will cause immense embarrassment.
• Ask about smoking and alcohol consumption. If there is any reason to suspect excessive consumption of alcohol the article on alcoholism- diagnosis and management in primary care contains help and advice.
  • Replies like, "I just drink socially," are meaningless as they depend upon the company one keeps.
  • Does the patient drink every day?
  • Record exact amounts smoked and drunk and if a range is given record the upper figure as it is more likely to be accurate.
• Ask about medication and make it clear that this means not just prescribed medication but drugs bought over the counter, "alternative remedies" and illicit drugs.
  • Herbal remedies can cause hepatitis.
  • Opiate abuse will cause nausea, anorexia and constipation.
  • Intravenous drug abuse carries a risk of hepatitis C, hepatitis B and HIV infection.
  • Cocaine and amphetamine derivatives cause appetite suppression.
  • Anabolic steroid abuse can cause hepatitis and even hepatocellular carcinoma.
  • In what form are drugs taken? NSAIDs as suppositories may still cause gastritis as the drug is transported to the stomach in the blood. There is also a high risk of proctitis.
  • The patient may admit to visiting health spas and receiving colonic lavage or high colonic irrigation.
• If there is proctitis a delicate enquiry as to the person's sexual predilection may be required in both males and females.
• Does the patient eat a normal diet? Changes in eating habits may have resulted from the symptoms.
• Note family history.
• Ask about foreign travel and living abroad. Travellers' diarrhoea is just one possibility. Many other exotic diseases can be acquired.

This is covered in a number of other articles too.

• Abdominal examination gives a general account and is orientated to examination of the acute abdomen or abdominal masses.
• Specific areas with problems are covered in:
  • Left upper quadrant pain
  • Right upper quadrant pain
  • Right iliac fossa pain
  • Left iliac fossa pain
  • Loin pain.
• Children pose specific difficulties and examination of children has its own article.

As always examination begins by looking at the patient.

A general inspection precedes inspection of the abdomen.

• How is the nutrition of the patient? Is the patient thin and wasted, bloated and oedematous or obese?
• Does the skin look pale or yellow? In black people a slightly yellow colour of the palms is equivalent to pallor.
• Features of scleroderma may account for dysphagia.
• Look for liver palms and a hepatic flap as described in examination of the abdomen.
• Look for abnormalities of the nails such as clubbing or koilonychia.
• Check the sclerae for jaundice.
• Note the angles of the mouth. Angular cheilitis may suggest iron deficiency. In pernicious anaemia around 50% of patients have a smooth tongue with loss of papillae but this can also be due to friction in those with a plastic palate with upper dentures.
• Does the mouth look healthy?
• Is dentition good?
• Is there halitosis?
• Oral candida may be associated with oesophageal candidiasis, especially if immunity is suppressed.

Only now is it time to turn to the abdomen and as always, first look.

• Abdominal distension may be apparent.
• Abdominal masses may be apparent on inspection.
• High pressure in the abdomen may cause protrusion of the umbilicus. Cirrhosis or portal hypertension may produce prominent blood vessels on the abdomen.

Now it is time for palpation and again reference is made to examination of the abdomen which also includes palpating for splenomegaly and detection of ascites. Hepatomegaly can be difficult to detect and it is often useful to percuss the liver edge. The liver is dull to percussion while bowel is resonant.

• Check for herniae. Femoral hernia is uncommon but very liable to strangulate.
• In secondary care the dictum is that no abdominal examination is complete without rectal examination. In primary care this is less vigorously applied, especially if the finding are unlikely to affect management.
• Few GPs have the skills or resources for sigmoidoscopy but proctoscopy and digital rectal examination should be within the capacity of everyone.
• Such examination may reveal rectal prolapse or an obvious cause of rectal bleeding although haemorrhoids are so common that they do not exclude other causes of bleeding.
• Carcinoma of the rectum may well be palpable.
• If an elderly person has diarrhoea, it is distinctly possibility that it is really spurious diarrhoea caused by faecal impaction with overflow. Therefore, before starting medication that may aggravate constipation it is imperative to perform a rectal examination. The old adage is, "Put your finger in it before you put your foot in it."

Investigations will be guided by findings on history and examination.

Blood tests

• FBC is fundamental and further investigation of iron status, folate and vitamin B12 may be indicated.
• Iron deficiency may be dietary but loss of blood is the assumed aetiology. Iron loss may cause iron deficiency anaemia or non-anaemic iron deficiency.
• Folate deficiency may also be dietary but in this context often indicates malabsorption.
• Dietary deficiency of vitamin B12 can be achieved with only the most severe vegan diet. Hence malabsorption is assumed. Autoimmune pernicious anaemia is not the only cause. Disease of the stomach may inhibit production of intrinsic factor and disease of the terminal ileum, including Crohn's disease, affects the area where vitamin B12 is absorbed.
• U&E with creatinine is a basic test. They may be abnormal in cirrhosis.
• Abnormal liver function tests may indicate a number of pathologies.
• Plasma proteins are also useful.
• Hypercalcaemia can produce abdominal pain even without stones. It is said to be associated with stones, bones and groans.

Endoscopy and imaging

• If peptic ulcer is considered then investigation should be along the NICE guidelines for dyspepsia. The NICE guidelines on Management of Dyspepsia in Adults³ states that endoscopy is not required unless the patient is presenting for the first time above the age of 55 or unless there are other warning signs. Warning signs include:
  • GI bleeding
  • Dysphagia
  • Unintentional weight loss
  • Abdominal swelling
  • Persistent vomiting.
• If peptic ulcer is suspected, tests should be performed for Helicobacter pylori. Endoscopy has largely superseded barium meal and follow through.
• If oesophageal obstruction is suspected, barium swallow should precede endoscopy as described in the relevant articles.
• The value and limitations of the plain abdominal x-ray are discussed elsewhere.
• Ultrasound is the technique of choice to diagnose gallstones and often disease of the pancreas although techniques such as Endoscopic Retrograde Cholangiopancreatography (ERCP) are performed more often.
• Ultrasound is also useful to investigate the liver.
• CT or MRI scans may also be valuable at times.
• If disease of the colon or rectum is suspected, sigmoidoscopy is required. Traditionally this has involved a rigid instrument but flexible sigmoidoscopes are less uncomfortable for the patient, easier to use and can usually reach further.
• Barium enema, usually with double contrast, or colonoscopy are used to visualise the colon. The examination should reach the ileo-caecal valve. Both must be preceded by sigmoidoscopy and this is why GPs are normally denied direct access to barium enema. Exceptions will usually be made for doctors who perform sigmoidoscopy.

Stool

• Stool samples may need to be analysed for occult blood, fat content, cysts, ova and parasites.

Irritable bowel syndrome

IBS is really a diagnosis of exclusion. It should not be over-investigated as the only positive feature is severe pain and spasm on barium enema. However, it should not be diagnosed when presenting for the first time over the age of 40 without full investigation.

This includes two important aspects:

Be aware of the warning signs that may indicate malignancy.

• Malignancy should be considered with significant, unintentional weight loss, progressive dysphagia, chronic blood loss, persistent vomiting and change of bowel habit in excess of 6 weeks duration especially over the age of 40.
• Dyspepsia presenting for the first time over 55 or IBS presenting for the first time over 40 are also warning features.

• In females think of gynaecological conditions but they rarely cause pain outside the pelvis.
• Note the full differential diagnosis of pain in the chest. Both chest pain and epigastric pain can be cardiac in origin and many a patient with "indigestion" has died of heart disease.
• Abdominal pain can be from the urinary tract or a dissecting abdominal aortic aneurysm.
• Thyrotoxicosis can cause weight loss.
• Congestive heart failure can cause engorgement of the liver.
• Metabolic disease such as porphyria can cause abdominal pain.
• Depression or psychotic illness can cause hypochondriacal or bizarre symptoms. Recognition of depression is not always easy but remember that depression can result from somatic illness and is not necessarily the cause.

Screening for depression in primary care may be employed if there is suspicion.

Children, especially when small, represent an entirely different problem from adults.

• An important feature for children and babies is failure to thrive. Centile charts plotting weight and possibly height with time are extremely useful.
• Children vomit very easily and are often remarkably unperturbed by it. Parents will recall how a child has vomited during a meal and before they have finished clearing it up the child is eagerly finishing the meal.
• Vomiting with a high temperature, unrelated to the gastro-intestinal tract, is common.
• The frequency of defaecation in milk fed babies is extremely variable as there is little residue, especially if they are breast fed.
• If children are asked where it hurts, they usually point to the umbilicus, even if the primary lesion is tonsillitis or otitis media.
• Acute surgical problems in children can be very difficult to diagnose.

Examining children also presents special difficulties that are covered in the relevant article.

If rectal examination is required for a baby, use the little finger as it is smallest. Think carefully before performing a rectal examination on an older child as it may be as traumatic as sexual abuse.