Gastroenterology

Ralph Boulton, Claire Cousins, Sanjeev Gupta, Humphrey Hodgson

• Publisher: CRC Press
• Year: 2011
• eBook ISBN: 9781482261257
• Edition: 2
• Topic: Medicine
• Subtopic: Gastroenterology & Hepatology

Combining the advantages of a color atlas with those of a short text, the authors provide systematic coverage of the diseases and disorders of the digestive tract. The book is filled with high quality color imaging and diagrams and includes the latest developments in investigation and management with special attention to refinements in endoscopy an

CHAPTER 1

Gastroenterological problems

Elicit an accurate history Examine the patient

Gastroenterological disease can cause systemic symptoms

Systemic disease can cause gastroenterological symptoms

Introduction

Gastroenterological problems encompass the entire range of pathology, including neoplasm, infection, inflammation, immunological disorders, biochemical, metabolic and congenital conditions, and disorders of unknown cause. In addition, approximately one-third of the gastrointestinal symptoms of outpatients have no identifiable structural, infective, or biochemical disorder present – they appear as ‘functional disorders’. Within such disorders, psychological or social factors may be primarily responsible. Identification and correct management depends on accurate history taking, clinical examination, and specialist investigations.

Approach to the patient

Some cardinal symptoms focus attention on one particular organ, and dictate the most effective and economical investigational path. Be aware that some disease processes outside the abdomen may present with abdominal symptoms, and consider the patient as a whole.

Major presenting complaints

DIFFICULTY IN SWALLOWING (DYSPHAGIA)

Difficulty in transferring food from the mouth to the stomach is termed dysphagia. This is an important symptom and it is useful to distinguish between the two phases of the normal swallow. The initial oropharyngeal phase, during which a food bolus is moved from the mouth to the oesophagus, is under voluntary control. This is followed by the oesophageal phase, which is involuntary.

Difficulty in starting the swallow – oropharyngeal dysphagia

This relates to neurological or muscular diseases (bulbar, pseudobulbar palsy, motor neurone disease, myasthenia gravis). It is often associated with drooling due to difficulty in swallowing saliva, or aspiration of saliva and aspiration pneumonia. There may be associated problems with voice production.

Food sticking after swallowing has started – oesophageal dysphagia

This suggests the presence of a structural lesion in the oesophagus. Some patients can actually localize the level of food sticking, while others cannot.

The nature of food that elicits symptoms should be clarified. Dysphagia initially for liquids is more likely to reflect problems in muscular or neural control of swallowing. Dysphagia initially for solids is likely to reflect a structural lesion in the oesophagus. Progressive dysphagia, first for solids, then for sloppy food and liquids, is a sinister sign that is strongly suggestive of cancer of the oesophagus, although this can occur with peptic strictures from recurrent oesophagitis.

Nonprogressive dysphagia may suggest a benign structural lesion (e.g. mucosal web in upper oesophagus, benign ‘ring’ in lower oesophagus). Intermittent food sticking, affecting both solids and liquids, suggests disordered motility (achalasia, oesophageal spasm).

With any oesophageal obstruction, regurgitation of food and liquid into the mouth may occur. The fluid is bland and not bitter, as it does not contain gastric acid. Nocturnal regurgitation may be associated with choking, aspiration, pneumonia, or asthma.

Lump in throat (globus hystericus or globus sensation)

During stress, highly anxious individuals may complain of a sensation of a lump in the throat without having eaten or drunk, often with temporary inability to swallow. This is a temporary functional disorder associated with anxiety. It is more common in women and, although investigations are frequently normal, it is sometimes associated with other oesophageal conditions (reflux disease and motility disorders). Gastropharyngeal reflux accounts for the symptoms in some.

LOSS OF APPETITE

This is highly nonspecific, but may be functional if associated with anxiety or depression. When associated with weight loss, it suggests significant organic disease. A maintained appetite is a reassuring sign that serious disease is less likely to be found. Early satiety (initial hunger but a rapid feeling of fullness after commencing eating) may reflect a poorly distensible stomach or a motility disorder.

NAUSEA AND VOMITING

These are nonspecific symptoms. In young men, morning nausea and retching without vomiting strongly suggests alcoholism. In young women, morning nausea suggests pregnancy. Nausea occurs with many abdominal pains, particularly those reflecting spasm of smooth muscle. Examples include an obstructed biliary tract, or spasm of the colon in functional bowel disease. Vomiting is a more significant disturbance involving reverse peristalsis and expulsion of gastric contents. It is rare as a purely functional disorder, although in a few patients ‘hysterical vomiting’ is the final diagnosis, generally reflecting severe family stress. More often, vomiting reflects organic disease affecting the stomach, duodenum, or small intestine.

Short-lived vomiting with fever and diarrhoea suggests food poisoning (bacteria, bacterial toxins, viral gastroenteritis).

Prolonged vomiting over more than a few days needs further investigation. In the absence of pain, persistent vomiting suggests obstruction of the outflow tract of the stomach, as seen with antral carcinoma or narrowing of the pylorus due to long-standing duodenal ulceration.

The nature of vomitus may be significant. Vomiting food ingested many hours previously suggests obstruction of the gastric outlet, as the stomach normally empties within 4–6 hr of eating. Vomiting of blood is discussed below.

Vomiting must be distinguished from regurgitation (food returning to mouth from gullet without reverse peristalsis), and from waterbrash (the mouth filled with salty water due to excess saliva, sometimes a symptom of peptic ulceration).

Both vomiting and nausea can reflect events elsewhere in the body (e.g. raised intracranial pressure, severe metabolic complications such as renal failure, side effects of drugs). Prolonged vomiting can induce metabolic changes, for example hypokalaemic alkalosis and secondary potassium loss from the kidneys.

PAIN

This is the most common reason for referral to gastroenterologists. Classic symptom complexes are sometimes recognizable, but some pains are poorly characterized and localized. The site and radiation of pain should be defined, and its duration (minutes or hours) noted. Pain character should also be noted – is the pain sharp, dull, or intermittent? Periodicity details should be noted – whether pain occurs all day, occasionally but every day, or every day for some weeks and then not at all for some months, is important diagnosticall...

Table of contents

• Cover
• Title Page
• Copyright Page
• Table of Contents
• Preface
• Acknowledgements
• Contributors
• Abbreviations
• Chapter 1 Gastroenterological problems
• Chapter 2 Mouth and pharynx
• Chapter 3 Oesophagus
• Chapter 4 Stomach and duodenum
• Chapter 5 Jejunum and ileum
• Chapter 6 Pancreas
• Chapter 7 Biliary conditions
• Chapter 8 Colonic disease
• Chapter 9 Gastrointestinal bleeding
• Chapter 10 Miscellaneous conditions
• Appendix
• Index