Evaluation of the Gastrointestinal Patient

The gastrointestinal (GI) tract is the main entry for fluids and nutrients into our body, and also the main way waste leaves our body. Many different medical conditions, not only those directly connected with the GI tract, cause GI symptoms.

GI symptoms include:

• Bleeding
• Bloating
• Constipation
• Diarrhea
• Heartburn
• Incontinence
• Nausea and vomiting
• Pain in the stomach or abdomen
• Swallowing problems
• Weight gain or loss.

Conditions may range from mild to serious. Common gastrointestinal conditions include:

• Cancer
• Dyspepsia, indigestion, and heartburn
• Esophagus problems, such as stricture (narrowing) and achalasia, and esophagitis
• Gallstones, cholecystitis, and cholangitis
• Gastroesophageal reflux disease (GERD), peptic ulcer disease, and hiatal hernia
• Intestinal problems, such as polyps and cancer, infections, celiac disease, Crohn's disease, ulcerative colitis, diverticulitis, malabsorption, short bowel syndrome, and intestinal ischemia
• Irritable bowel syndrome
• Lactose intolerance
• Liver problems, such as hepatitis B or hepatitis C, cirrhosis, liver failure, and autoimmune and alcoholic hepatitis
• Pancreatitis and pancreatic pseudocyst
• Rectal problems, such as anal fissure, hemorrhoids, proctitis, and rectal prolapse
• Stomach problems, including gastritis, gastric ulcers (usually caused by Helicobacter pylori infection), and gastric cancer.

A thorough and accurate medical history will be taken by your healthcare provider, noting the symptoms you have experienced and any other relevant information. A physical examination is also done to help assess the problem more completely.

History

It is important to identify the location and severity of the symptoms and any aggravating and alleviating factors. If abdominal pain is present, the location can help narrow down the diagnosis, for example, pain in the:

• Epigastrium may be associated with problems in the pancreas, stomach, or small bowel
• Right upper quadrant may reflect problems in the liver, gallbladder, and bile ducts such as cholecystitis or hepatitis
• Right lower quadrant may indicate inflammation of the appendix, terminal ileum, or cecum, suggesting appendicitis, ileitis, or Crohn's disease
• Left lower quadrant may indicate diverticulitis or constipation
• Either left or right lower quadrant may indicate colitis, ileitis, or ovarian (in women) etiologies.

Asking patients about the character (sharp and constant, waves of dull pain), onset (sudden or gradual) or radiation of pain may help with the diagnosis, for example:

• Pain radiating to the shoulder may reflect cholecystitis because the gallbladder may be irritating the diaphragm
• Pain radiating to the back may reflect pancreatitis.

Ask about changes in their eating or bowel habits:

• Do they have difficulty swallowing (dysphagia), loss of appetite, or nausea and vomiting?
• If vomiting, how often and for how long? Is there any blood or coffee-ground–like material suggestive of GI bleeding?
• What fluids have you had to drink and how much? Have you been able to keep them down?
• When did you last go to the toilet? Are you going more or less often than usual for you? Describe the color and consistency of your stool; does it appear black or bloody (suggestive of GI bleeding), or is there mucus?

Ask women about their gynecologic history because gynecologic and obstetric disorders may cause GI symptoms.

Also, assess nonspecific symptoms such as fever or weight loss. Weight loss may indicate a more severe problem such as cancer.

Take into account the subjective nature of reporting symptoms such as nausea and vomiting, which may be minimized or reported indirectly by a severely depressed patient but dramatized by others.

Question patients about previously diagnosed GI disorders, previous abdominal surgery, and use of drugs and substances that might cause GI symptoms (such as nonsteroidal anti-inflammatory drugs [NSAIDs], alcohol, prednisone, or cannibis).

Symptoms can be grouped as to those that affect ingestion, digestion, absorption, or nutritional status. Many other conditions, not directly related to the GI tract, such as anxiety, depression, or pain, can cause GI symptoms, so consider all conditions.

Table 1. Gastrointestinal disorders

Physical Examination

Good lighting and a stethoscope are all that is needed for a physical examination of the GI patient.

• Start with the mouth and throat to assess hydration, ulcers, or possible inflammation.
• Lie the patient down and look at the abdomen. This may be rounded or bloated when a bowel obstruction, ascites, or, rarely, a large mass is present. Listen and assess bowel sounds and determine the presence of bruits. Tapping the abdomen (percussion) elicits tympany if there is bowel obstruction or dullness with ascites and can indicate liver enlargement.
• Palpatate the abdomen systematically to identify areas of tenderness or to locate masses or enlarged organs. Look for guarding and rebound.
• Palpitate the inguinal area and all surgical scars for hernias.
• If anorectal disorders are suspected perform a digital rectal examination and test for occult blood.
• In women, perform a pelvic examination if necessary.

Tests and Procedures

Tests and procedures depend on what underlying condition is suspected and may include:

• Blood, urine, and stool samples
• Imaging studies such as x-rays, CT scan, MRI, or ultrasound
• Colonoscopy and endoscopy of the large intestine, esophagus, or stomach
• Stomach acid analysis to look at stomach pH levels
• Wireless capsule endoscopy to take pictures of the small intestine
• Hydrogen breath testing to study issues like bloating, diarrhea, and constipation
• Sitz Marker Study to see how fast stool moves through the colon
• Motility studies
• Biopsy.