Gastrointestinal disease can present with a wide variety of symptoms affecting oral intake, the abdomen, bowel motions and the patient's constitution. By taking a thorough history it is possible to narrow down the differential diagnosis and guide clinical examination.
Start by asking the patient about their main reason for presenting.
- Common gastrointestinal symptoms include:
- Abdominal pain
- Nausea & vomiting
- Change in bowel motions - constipation, diarrhoea or faecal incontinence
- Blood in bowel motions - fresh blood (haematochezia), or black, tarry stools (malaena)
- Anorectal symptoms - anorectal pain, masses or the sensation of incomplete emptying (tenesmus)
- Weight change - weight loss or weight gain
- Yellow discolouration of the skin (jaundice)
- Swallowing problems - difficulty swallowing (dysphagia), pain on swallowing (odynophagia) or dry mouth
History of Presenting Complaint
When asking for more information about a patient’s symptoms, start by asking general questions such as “could you please tell me more about that”, and then narrow down the questions as more information is provided.
- Generally speaking, the following questions are a good starting point for any type of pain, and may be useful in gaining information about other symptoms:
- Site - localised or generalised; unilateral or bilateral
- Onset - sudden or gradual, and what the situation was (e.g. following trauma)
- Character - sharp, dull, burning or pressure-like
- Radiation - e.g. down the arm or across the back
- Associated symptoms - e.g. fevers, nausea / vomiting, bony pain
- Timing - duration of symptoms, frequency of episodes, changes through the day
- Exacerbating & alleviating factors - e.g. exacerbation with exertion and alleviation with rest
- Severity - on a scale of 1 to 10, with 10 being the worst
Past Medical History
Ask about any medical conditions the patient has previous been diagnosed with, the management of these conditions, and any complications they may have.
Gastrointestinal DiseaseCommon gastrointestinal disorders include:
- Gastroesophageal reflux disease
- Peptic ulcer disease
- Inflammatory bowel disease - Crohn's disease, ulcerative colitis
- Coeliac disease
- Diverticular disease
- Anorectal disease - fissures, fistulas, ulcers, haemorrhoids
- Herniae - inguinal, femoral, umbilical, ventral
- Irritable bowel syndrome
- Ask about any abdominal surgery the patient may have had in the past, such as cholecystectomy or appendicectomy. If a patient has had a stoma formed in the past, ask about the location of the stoma (ileostomy / colostomy), output of the stoma, any complications they have had as a result.
Enquire about any past colonoscopies, such as for colorectal cancer screening, and the results.
- The workup and management of liver transplant patients is complex and includes physical, psychological and social factors.
Ask about what medications the patient takes regularly, what they take them for, and what side effects they have had.
Certain medications are likely to cause gastrointestinal symptoms. Opioids and oral iron supplements are particularly associated with constipation, while NSAIDs, antiplatelets and anticoagulants put patients at risk of GI bleeding. Chemotherapeutic agents are particularly associated with nausea and vomiting.
Ask about any medical conditions that may be known in the family.
In a patient with GI bleeding or systemic symptoms such as fevers, lethargy and weight loss, always ask about family history of cancer. Gastrointestinal malignancies include oesophageal, gastric, pancreatic and colorectal cancers.
In patients with jaundice / unexplained liver disease, ask about a family history of haemochromatosis, Wilson’s disease and alpha-1 antitrypsin deficiency.
In patients with suspected inflammatory bowel disease or coeliac disease, ask about a family history of autoimmune conditions. This may include IBD, rheumatoid arthritis, systemic lupus erythematosus or multiple sclerosis.
It is important to understand any patient’s social situation when taking their history. This includes key aspects such as their occupation (or previous occupation, if retired), living situation, mobility, ability to perform activities of daily living, diet and exercise.
In patients with a suspected infective gastroenteritis, ask about recent travel or any recent dietary changes.
In patients being worked up for liver transplant, the social history becomes an even more vital part of decision making. Such patients require a significant level of physical, social and psychological support and it is important to ensure that the patient has these in place prior to considering these interventions. This may include ensuring that they have someone to drop them off to appointments; that they are likely to take their medications regularly; and that they are unlikely to do anything that would put them at risk such as returning to alcohol.
Ask about alcohol intake, as this is a significant risk factor for alcoholic liver disease / cirrhosis, pancreatitis and malnutrition. Ask how many drinks the patient has per week, what type of drinks, and whether they have considered cutting down their intake if heavy.
Take a detailed smoking history: identify how many years the patient has smoked for, how many they smoked per day, and how long since they quit (if applicable. Smoking is a risk factor for gastric, colorectal and pancreatic cancer.
Finally, ask about recreational drug use, and particularly intravenous drug use. IV drug use is associated with blood-borne viral infections including hepatitis B and C.
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