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 patientâ€™s symptoms, start by asking general questions such as â€œcould you please tell me more about thatâ€, 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, Wilsonâ€™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 patientâ€™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.
Want more info like this?
- Your electronic clinical medicine handbook
- Guides to help pass your exams
- Tools every medical student needs
- Quick diagrams to have the answers, fast
- Quizzes to test your knowledge
Ananthakrishnan AN. Epidemiology and risk factors for IBD. Nature reviews Gastroenterology & hepatology. 2015 Apr;12(4):205.Apau D. Assessing abdominal pain through history taking and physical examination. Gastrointestinal Nursing. 2010 Sep; 8(7): 50 - 53.
Arce DA, Ermocilla CA, Costa HI. Evaluation of constipation. American family physician. 2002 Jun 1;65(11):2283-98.Argyrou A, Legaki E, Koutserimpas C, Gazouli M, Papaconstantinou I, Gkiokas G, Karamanolis G. Risk factors for gastroesophageal reflux disease and analysis of genetic contributors. World journal of clinical cases. 2018 Aug 16;6(8):176.Armstrong MJ, Adams LA, Canbay A, Syn WK. Extrahepatic complications of nonalcoholic fatty liver disease. Hepatology. 2014 Mar;59(3):1174-97.Astor FC, Hanft KL, Ciocon JO. Xerostomia: a prevalent condition in the elderly. Ear, nose, & throat journal. 1999 Jul;78(7):476-9.
Bates CM, Plevris JN. Clinical evaluation of abdominal pain in adults. Medicine. 2013 Feb 28;41(2):81-6.Chlabicz S, Flisiak R, Grzeszczuk A, Kovalchuk O, Prokopowicz D, Chyczewski L. Known and probable risk factors for hepatitis C infection: a case series in north-eastern Poland. World Journal of Gastroenterology: WJG. 2006 Jan 7;12(1):141.Collin GR, Russell JC. Endometriosis of the colon. Its diagnosis and management. The American surgeon. 1990 May;56(5):275-9.Corinaldesi R, Stanghellini V, Barbara G, Tomassetti P, De Giorgio R. Clinical approach to diarrhea. Internal and Emergency Medicine. 2012 Oct; 7(3 Suppl): 255-262.Drossman DA, Dumitrascu DL. Rome III: New standard for functional gastrointestinal disorders. Journal of Gastrointestinal and Liver Diseases. 2006 Sep;15(3):237.Elias E. Clinical and biochemical diagnosis of jaundice. Bailliere's Clinical Gastroenterology. 1989 Apr; 3(2): 357-385.Eskelinen M. Usefulness of history-taking in non-specific abdominal pain: a prospective study of 1333 patients with acute abdominal pain in Finland. In vivo 2012 Mar; 26 (2): 335.Feuerstein JD, Cheifetz AS. Ulcerative colitis: epidemiology, diagnosis, and management. InMayo Clinic Proceedings 2014 Nov 30 (Vol. 89, No. 11, pp. 1553-1563).Fields JM, Dean AJ. Systemic causes of abdominal pain. Emergency medicine clinics of North America. 2011 May 31;29(2):195-210.
Galossi A, Guarisco R, Bellis L, Puoti C. Extrahepatic manifestations of chronic HCV infection. Journal of Gastrointestinal and Liver Diseases. 2007 Mar 1;16(1):65.Gaude GS. Pulmonary manifestations of gastroesophageal reflux disease. Annals of thoracic medicine. 2009 Jul;4(3):115.Han SH. Extrahepatic manifestations of chronic hepatitis B. Clinics in liver disease. 2004 May;8(2):403-18.Hu XY, Li Y, Li LQ, Zheng Y, Lv JH, Huang SC, Zhang W, Liu L, Zhao L, Liu Z, Zhao XJ. Risk factors and biomarkers of non-alcoholic fatty liver disease: an observational cross-sectional population survey. BMJ open. 2018 Apr 1;8(4):e019974.Ingelfinger FJ. Differential diagnosis of jaundice. Disease-a-Month. 1958 Nov; 4(11): 1-42.Jamshed N, Lee ZE, Olden KW. Diagnostic Approach to Constipation in Adults. American Family Physician. 2011; 84(3): 299-306.Jensen T, Niwa K, Hisatome I, Kanbay M, Andres-Hernando A, Roncal-Jimenez CA, Sato Y, Garcia G, Ohno M, Lanaspa MA, Johnson RJ. Increased serum uric acid over five years is a risk factor for developing fatty liver. Scientific reports. 2018 Aug 6;8(1):11735.Johnson CM, Wei C, Ensor JE, Smolenski DJ, Amos CI, Levin B, Berry DA. Meta-analyses of colorectal cancer risk factors. Cancer causes & control. 2013 Jun 1;24(6):1207-22.Kappus MR, Sterling RK. Extrahepatic manifestations of acute hepatitis B virus infection. Gastroenterology & hepatology. 2013 Feb;9(2):123.Kirchhoff P, Clavien PA, Hahnloser D. Complications in colorectal surgery: risk factors and preventive strategies. Patient safety in surgery. 2010 Dec;4(1):5.
Lee L, Blaker P, Wilkinson M. Chronic constipation: current assessment and management. Prescriber-London. 2012 Dec 1;23(23):13.Levine JS, Burakoff R. Extraintestinal manifestations of inflammatory bowel disease. Gastroenterology & hepatology. 2011 Apr;7(4):235.Locke III GR, Talley NJ, Fett SL, Zinsmeister AR, Melton III LJ. Risk factors associated with symptoms of gastroesophageal reflux. The American journal of medicine. 1999 Jun 1;106(6):642-9.Macaluso CR, McNamara RM. Evaluation and management of acute abdominal pain in the emergency department. International journal of general medicine. 2012;5:789.McNamara R, Dean Aj. Approach to Acute Abdominal Pain. Emergency Medicine Clinics of North America. 2011 May; 29(2):159-173.Metz A, Hebbard G. Nausea and vomiting in adults: A diagnostic approach. Australian family physician. 2007 Sep 1;36(9):688.Milosavljevic T, Kostić-Milosavljević M, Jovanović I, Krstić M. Complications of peptic ulcer disease. Digestive diseases. 2011;29(5):491-3.Molodecky NA, Kaplan GG. Environmental risk factors for inflammatory bowel disease. Gastroenterology & hepatology. 2010 May;6(5):339.Napenas JJ, Brennan MT, Fox PC. Diagnosis and treatment of xerostomia (dry mouth). Odontology. 2009 Jul 1;97(2):76-83.Nilsson M, Johnsen R, Ye W, Hveem K, Lagergren J. Lifestyle related risk factors in the aetiology of gastro-oesophageal reflux. Gut. 2004 Dec 1;53(12):1730-5.Pfenninger JL, Zainea GG. Common anorectal conditions: Part I. Symptoms and complaints. American family physician. 2001 Jun;63(12):2391-8.Quigley EM, Hasler WL, Parkman HP. AGA technical review on nausea and vomiting. Gastroenterology. 2001 Jan 31;120(1):263-86.R SM. Evaluating dysphagia. Am Fam Physician. 2000;61:3639-3648.Rabinovitz M, Pitlik SD, Leifer M, Garty M, Rosenfeld JB. Unintentional weight loss: a retrospective analysis of 154 cases. Archives of internal medicine. 1986 Jan 1;146(1):186-7.Ramakrishnan K, Salinas RC. Peptic ulcer disease. American family physician. 2007 Oct 1;76(7).Roden DF, Altman KW. Causes of dysphagia among different age groups: a systematic review of the literature. Otolaryngologic Clinics of North America. 2013 Dec 31;46(6):965-87.Schechter GL. Systemic causes of dysphagia in adults. Otolaryngologic Clinics of North America. 1998 Jun 1;31(3):525-35.Schiller LR. Chronic diarrhea. Gastroenterology. 2004 Jul 31;127(1):287-93.Segal WN, Greenberg PD, Rockey DC, Cello JP, McQuaid KR. The outpatient evaluation of hematochezia. The American journal of gastroenterology. 1998 Feb 1;93(2):179-82.Vanni E, Marengo A, Mezzabotta L, Bugianesi E. Systemic complications of nonalcoholic fatty liver disease: when the liver is not an innocent bystander. InSeminars in liver disease 2015 Aug (Vol. 35, No. 03, pp. 236-249). Thieme Medical Publishers.Walker CL, Sack D, Black RE. Etiology of diarrhea in older children, adolescents and adults: a systematic review. PLoS Negl Trop Dis. 2010 Aug 3;4(8):e768.Watcha MF, White PF. Postoperative nausea and vomiting. Its etiology, treatment, and prevention. Anesthesiology. 1992 Jul;77(1):162-84.White GN, O'Rourke F, Ong BS, Cordato DJ, Chan DK. Dysphagia: causes, assessment, treatment, and management. Geriatrics. 2008 May 1;63(5).Yeh EL. Abdominal Pain. Clinics in geriatric medicine. 2007 May; 23 (2): 255.