AQ:

• Kindly check and verify the yellow highlighted text. Also provide citation for Table 5.
• Kindly provide the subhead of Tables 1 and 3, if required.

CHAPTER

2 Clinical Approach to a Patient with

Gastrointestinal Disease
AC Anand, Bipadbhanjan Mallick

INTRODUCTION TABLE 1: Causes of dysphagia.

Oropharyngeal Neurological • Cerebrovascular accident
The abdomen has been called a Pandora’s box. Literally, it
or high • Motor neuron disease
means a place or process that generates many complicated dysphagia
problems. Patients with gastrointestinal (GI) diseases • Parkinson’s disease
are a real test of the clinical acumen of a physician as • Multiple sclerosis
the diagnosis requires a meticulous history thorough • Myasthenia gravis
physical examination and carefully selected set of investi- • Muscular dystrophy
gations. Symptoms such as dysphagia, heartburn, abdo- Anatomical • Oropharyngeal malignancy
minal pain, nausea, vomiting, and hematemesis point to or muscular (uncommon)
diseases of the upper GI tract, while constipation, diarrhea, • Corrosive injury
and hematochezia are commonly due to diseases of the • Zenker’s diverticulum
lower GI tract. However, symptoms may overlap in a variety • Retropharyngeal abscess
of diseases. • Cervical osteophyte
• Cervical web
• Chemotherapy mucositis
DYSPHAGIA, ODYNOPHAGIA, AND
Low Motility • Achalasia
HEARTBURN esophageal disorder • GERD with weak peristalsis
Dysphagia, odynophagia, and heartburn are caused by dysphagia (propulsive) • Scleroderma
esophageal diseases. Dysphagia is difficulty in passage • Chagas disease
of solids or liquids from the mouth to the stomach. It • Diffuse esophageal spasms
should be distinguished from odynophagia, which is Mechanical • Eosinophilic esophagitis (Food
pain on swallowing. Heartburn is a burning sensation obstruction impaction)
behind the sternum often related to GI reflux. A related • Schatzki ring (intermittent)
symptom is “Globus sensation” which is defined as a • Webs (intermittent)
persistent or intermittent sensation of a lump or tightness • Neoplasm (progressive)
in the throat, unrelated to swallowing. Globus sensation • Pill esophagitis (odynophagia)
should not be diagnosed in the presence of dysphagia, • Peptic strictures (variable)
odynophagia, an esophageal motility disorder, or gastro- • Luminal foreign body impaction
esophageal reflux. • External compression by
Dysphagia is of two main types: (1) Oropharyngeal mediastinal mass
dysphagia results from diseases of the neuromuscular • Infectious esophagitis
mechanism of the mouth, hypopharynx, and upper (odynophagia)
esophagus, and the patient is unable to initiate and execute (GERD: gastroesophageal reflux disease)
the swallow mechanism. There may be coughing, choking,
or regurgitation of fluids from the nose while swallowing, in
addition to associated features of cranial nerve palsies in the NAUSEA, RETCHING, AND VOMITING
form of dysarthria and hoarseness of voice. (2) Esophageal
dysphagia is due to motility or structural disorders involving Nausea is an unpleasant feeling of urge to vomit; this may
the body of the esophagus and gastroesophageal junction. It be associated with autonomic features such as increased
can also be caused by external compression of esophagus or salivation and sweating. Retching is a strong involuntary
intraluminal causes such as food or foreign body impaction. effort at vomiting. Vomiting is the act of bringing out of
The common causes of dysphagia and the approach to gastric contents through the mouth.
diagnosis of a patient with dysphagia are summarized in Gastrointestinal disorders causing vomiting include
Table 1 and Flowchart 1, respectively. infections; bowel obstruction; motility disorders; and
 Gastroenterology
SECTION 19

TABLE 2: Alarm symptoms in a patient with bowel disorders

involving upper and lower gastrointestinal symptoms.
Patients presenting Symptoms that make the diagnosis
with dyspepsia of irritable bowel syndrome unlikely
• Anemia • Fever
• Weight loss • Weight loss
• Gastrointestinal bleed • Nocturnal diarrhea
(hematemesis or • Blood in stools
malena) • Anemia, low albumin, or high ESR
• Recent onset of • Recent symptoms in middle
progressive symptoms age/elderly
• Age >55 years
• Dysphagia
(ESR: erythrocyte sedimentation rate)
Note: In presence of these symptoms, one should in reatingate early, and avoid
making a diagnosis of functional bowel disease.

afferents to both sides of the spinal cord. Pain location

corresponds to those dermatomes that match the
innervation of the diseased organ. Generally, visceral
pain from abdominal organs proximal to the ligament of
Treitz is felt in the epigastrium; pain from organs between
the ligament of Treitz and the hepatic flexure of the colon
FLOWCHART 1: Approach to a case with dysphagia. is felt in the periumbilical region; and that from organs
* May be intermittent dysphagia in an esophageal ring.
beyond the hepatic flexure is perceived in the midline of
the lower abdomen. Pain arising in hollow organs may wax
inflammations such as cholecystitis, appendicitis, and and wane due to peristaltic waves (Fig. 1).
pancreatitis. Vomiting is often due to nongastrointestinal Parietal pain is well localized and sharp. It is due to
causes such as adverse effects of certain drugs, motion peritoneal irritation by the inflamed organ and may be
sickness, raised intracranial tension, meningitis, azotemia, associated with guarding of abdominal muscles as in
pregnancy, systemic illness, and psychogenic causes. appendicitis. Referred pain is felt in areas remote from
Associated symptoms such as abdominal pain and the involved organ, e.g., left shoulder pain due to splenic
constipation point to a GI etiology. Projectile vomiting abscess causing diaphragmatic irritation.
(without nausea) is suggestive of raised intra cranial Assessment of cause of abdominal pain includes a
tension. There may be stale food in vomitus in gastric careful history of onset, duration, progression, character,
outlet obstruction. The vomitus is bilious in obstruction location, radiation, aggravating and relieving factors.
distal to the duodenum. Vomiting of psychogenic etiology Clinical examination starts with inspection, which may
occurs during or soon after a meal, often on the dining show scars, hernias, splinting of abdominal movements
table. with respiration and visible peristalsis. A patient with peri-
tonitis would lie still, and the abdomen would be tender
DYSPEPSIA and feel rigid. In contrast, a patient with ureteric colic may
be rolling in bed and restless due to pain. Visible peristalsis
Dyspepsia comprises a group of upper abdominal may be seen in bowel obstruction. Palpation may show
symptoms including epigastric pain, burning, postprandial a lump or tenderness. Guarding or rebound tenderness
fullness and early satiation. Pain or discomfort is centered may suggest peritonitis. Percussion may show shifting
in the upper abdomen. Dyspepsia can be chronic or dullness in ascites or obliteration of hepatic dullness in
recurrent. Functional dyspepsia without any organic disease bowel perforation. Auscultation may reveal hyperactive
is possibly the most common diagnosis made in such cases. or absent bowel sounds. Rectal examination may reveal a
The warning signs and symptoms that should alert the rectal growth or a pelvic abscess.
physician to a possibility of a more serious disease are shown
in Table 2, and should prompt for an early investigation
such as endoscopy and imaging studies. GASTROINTESTINAL BLEEDING
Bleeding from the GI tract can present as hematemesis,
Abdominal Pain melena, hematochezia or occult bleed with anemia.
Abdominal pain may be visceral, parietal, or referred. Hematemesis is blood in vomitus, and indicates that
Visceral pain is dull cramping and poorly localized. It is the source of bleeding is either esophagus, stomach, or
2 often in the midline because abdominal organs transmit duodenum. It may be bright-red suggesting ongoing
 Clinical Approach to a Patient with Gastrointestinal Disease

CHAPTER 2
FIGURE 1: Common causes of pain in abdomen. The figure gives an idea about the value of localization of pain.
(GERD: gastroesophageal reflux disease)

bleeding or coffee-ground material in case bleeding TABLE 3: Differentiating variceal from nonvariceal bleed.
has stopped sometime earlier. Melena is black, tarry Variceal source suspected • Jaundice
foul-smelling stool and usually signifies the presence of if GI bleeding may be • Ascites
>50 mL of blood in the GI tract. It usually implies a associated with • Splenomegaly
proximal GI source. It takes about 12 hours of transit time • Past history of treatment for liver
for melena to develop. It can rarely develop as a result disease
of bleeding from right colonic pathology. Hematochezia • Clinical stigmata of chronic liver
(maroon bloody stools) signifies a lower GI source but disease (spider nevi, palmar
may also be due to proximal GI bleed if intestinal transit erythema, testicular atrophy,
is rapid. Fresh red blood is commonly due to rectal or left gynecomastia, etc.)
colonic disease. Occult GI bleeding refers to clinically Nonvariceal source is • Absence of the above
nonvisible bleeding and the usual presentation is that of suspected if bleeding is • History of epigastric pain
symptoms of anemia. associated with • Past history of peptic ulcer
Preliminary clues to the site of hemorrhage include • Recent NSAID and antiplatelet drug
the presence of hematemesis, hyperactive bowel sounds, intake
and increased blood urea nitrogen out of proportion to • Recurrent vomiting/retching
creatinine (upper GI), or fresh rectal bleeding (colonic). (Mallory–Weiss tear)
Insertion of a nasogastric tube and aspiration may help in (GI: gastrointestinal; NSAID: nonsteroidal anti-inflammatory drug)
localization of bleeding. However, it may be negative in
some cases of upper GI bleed, if the bleeding has stopped.
In upper GI bleeding, from a management point of view, it colonoscopy, enteroscopy) and imaging [computed
is important to differentiate between variceal and nonva- tomography (CT) with vascular contrast angiography) are
riceal etiology (Table 3). GI endoscopy (gastroendoscopy, used to b the site of bleed. GI endoscopy/colonoscopy/ 3
 Gastroenterology
SECTION 19

CT scan of abdomen/capsule endoscopy or enteroscopy is TABLE 4: Chronic diarrhea: Several clinical clues can guide
usually needed to determine the source of bleeding. toward diagnosis.
Clinical clues Possible causes
CONSTIPATION Clubbing Immunoproliferative small intestinal
disease, Crohn’s disease, celiac disease
Patients usually define constipation not only by infre-
Fever Tuberculosis, lymphoma, Whipple’s
quent stools (typically fewer than three per week), but also disease, Crohn’s disease/ulcerative colitis
by associated symptoms which are equally or probably
Response to antibiotics Bacterial overgrowth, giardiasis, tropical
more important, such as hard stools, the need for excessive sprue, Whipple’s disease
straining, a sense of incomplete bowel evacuation, and
Response to steroids Inflammatory bowel disease (IBD),
excessive time spent in the toilet or in unsuccessful microscopic colitis, eosinophilic
defecation. gastroenteritis, Addison’s disease
Constipation is a common symptom, more so in the Arthritis IBD, celiac disease, Whipple’s disease,
elderly. A number of commonly used drugs in the elderly collagen disorder
often aggravate constipation, including anticholinergic Lymphadenopathy HIV, Whipple’s disease, tuberculosis,
drugs, calcium supplements, iron supplements, diuretics, lymphoma
calcium-channel blockers, etc. A history of recent onset
Dermatitis herpetiformis Celiac disease
of constipation and/or blood mixed with stool raises the
Pyoderma gangrenosum IBD
possibility of a malignant colonic lesion.
A thorough physical examination should be performed Abdominal mass Malignancy including lymphoma,
Crohn’s disease, tuberculosis
to exclude systemic or neurological illnesses that may
cause constipation. Abdominal examination may reveal
abdominal mass or palpable stools. A per rectal examina- TABLE 5: Large bowel diarrhea versus small bowel diarrhea.
tion can give a lot of information. It gives a fair idea about Large bowel diarrhea Small bowel diarrhea
tone of anal sphincter and whether anal relaxation efforts
• Presence of blood and mucus • Malodorous, floating, greasy,
are synergistic with defecation efforts or not and rectal containing undigested food
• Rectal symptoms such as
fecoliths can be evacuated. Ano-rectal examination may tenesmus and urgency particles
also reveal fissures, hemorrhoids or a rectal stricture. • Small-volume jelly-like stools • Large-volume stools
Imaging of the colon by CT, magnetic resonance imaging • Mid-abdominal cramps with
• Associated hypogastric cramps
(MRI), barium enema study or colonoscopic examination borborygmi
would be required to rule out obstructing lesion as the
cause of constipation.

DIARRHEA
Diarrhea is defined as increase of volume, frequency,
or fluidity of stool. It could be acute or chronic. Acute
diarrhea (<4 weeks) is usually due to infections and is
often self-limited. It may be associated with fever, pain in
abdomen, or dehydration. Chronic diarrhea (>4 weeks)
may be associated with malabsorption and weight loss.
Chronic diarrhea can be classified on the basis of volume
(large vs. small), pathophysiology (secretory vs. osmotic)
and stool characteristics (watery, fatty, or inflammatory).
Frequent small volume stools point to left colonic pathology
whereas less frequent larger volume stools suggest right
colonic or small bowel source. Secretory diarrhea occurs
due to malabsorption, or secretion of electrolytes into
intestinal lumen. Osmotic diarrhea is caused by ingestion
of poorly absorbable solutes like osmotic laxatives and it
decreases with fasting. Chronic watery diarrhea implies
either secretory or osmotic diarrhea, fatty diarrhea indicates
defective fat absorption and inflammatory diarrhea implies
presence of inflammatory or neoplastic diseases involving FLOWCHART 2: Approach to chronic diarrhea: Basic clinical
GI tract. The clinical clues to etiology of chronic diarrhea are segregation of patient into small bowel diarrhea and large bowel
given in Table 4 and clinical approach to chronic diarrhea is diarrhea is usually adequate in directing evaluation. A small
shown in Flowchart 2. subgroup of patients with watery diarrhea, in whom evaluation for
4 the above have been negative, require advanced evaluation.
(IBS: inflammatory bowel disease)
 Clinical Approach to a Patient with Gastrointestinal Disease

CHAPTER 2
RECOMMENDED READINGS
1. Poddar U. Approach to Constipation in Children. Indian Pediatrics. 7. Strate LL, Naumann CR. The role of colonoscopy and radiological
2016;53:319-27. procedures in the management of acute lower intestinal bleeding.
2. Berman H, Brooks L, Silver S. A rational approach to constipation. Clin Gastroenterol Hepatol. 2010;8:333.
Geriatrics and Aging. 2007;10(10):654-60.  8. Andrade JA, Fagundes-Neto U. Persistent diarrhea: still an
3. Lacy BE. Functional dyspepsia and gastroparesis: one disease or important challenge for the pediatrician. J Pediatr (Rio J).
two? Am J Gastroenterol. 2012;07:1615. 2011;87:199.
4. Kahrilas PJ, Smout AJ. Esophageal disorders. Am J Gastroenterol. 9. Jalil AAA, Katzka DA, Castell DO. Approach to the Patient with
2010;105:747. Dysphagia. Am J Med. 2015;128(10):1138.e17-23.
5. Barkun AN, Bardou M, Kuipers EJ, Sung J, Hunt RH, Martel M, et al. 10. Wee EW. Evidence-based approach to dyspepsia: from Helicobacter
International consensus recommendations on the management pylori to functional disease. Postgrad Med. 2013;125(4):169-80.
of patients with nonvariceal upper gastrointestinal bleeding. Ann 11. Macaluso CR McNamara RM. Evaluation and management of
Intern Med. 2010;152:101. acute abdominal pain in the emergency department. Int J Gen
6. Tantiphlachiva K, Rao P, Attaluri A, Rao SS. Digital rectal examination Med. 2012;5:789-97.
is a useful tool for identifying patients with dyssynergia. Clin 12. Gu Y, Lim HJ, Moser MA. How useful are bowel sounds in assessing
Gastroenterol Hepatol. 2010;8:955. the abdomen? Dig Surg. 2010;27:422.