4 Gastrointestinal Reference Guide

This a guide for the gastrointestinal examination as well as the stuff you need to cover when doing a GI history.

Quick reference

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Common conditions

The common conditions are:

• Colorectal carcinoma
• Carcinoma of the stomach
• Carcinoma of the oesophagus
• Diverticular disease and Diverticulitis
• Irritable bowel disease
• Coeliac disease
• Acute hepatitis
• Inflammatory bowel disease (Crohn’s disease and ulcerative colitis)
• Gastro-oesophageal reflux disease
• Peptic ulcer disease
• Haemorrhoids
• Anal fissure And GI conditions causing an acute abdomen
• Appendicitis
• Diverticulitis
• Gastroenteritis
• Gallstones
• Bilary colic
• acute cholecystitis
• Acute pancreatitis
• Perforatied peptic ulcer
• Intestinal obstruction

GI associated symptoms

• mouth ulcers
• dysphagia
• indigestion, heartburn, dyspepsia, gastro oesophageal reflux
• nausea
• retching
• vomiting
• haematemesis
• melaena
• jaundice
• abdominal pain
• change in normal bowel habit
  • diarrhoea
  • constipation
  • overflow diarrheoa
  • rectal bleeding
  • tenesmus
  • steatorrhoea
• Wind flatulence

In Depth

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What are the common conditions

Colo-rectal carcinoma

This is a very common cancer. Symptoms include a change in bowel habit over weeks to months with looser, more frequent bowel motions, or constipation, rectal bleeding, tenesmus, and symptoms of anaemia such as tiredness, and shortness of breath. It can present with intestinal obstruction.

Carcinoma of the stomach / Gastric cancer

Gastric cancer is a common cancer worldwide. It is rare under the age of 30 and is more common in men. It is associated with H pylori infection that causes chronic gastritis. Diet, genetic factors, and tobacco smoking are all implicated. It presents with epigastric pain, relieved by food and antacids. It may be associated with dysphagia, nausea, vomiting, anorexia, and weight loss.

Carcinoma of the oesophagus

This is a relatively common cancer occurring mainly in people aged 60-70 years. It presents with progressive and unrelenting dysphagia. The patient often finds they are unable to swallow solids and within weeks begin to find even swallowing liquids is difficult. The patient may have reduced appetite and weight loss.

Diverticular disease and diverticulitis

Diverticular disease is a long-term condition that causes small flask-like pockets or outpouchings (diverticula) in the colon. It is also called diverticulosis. This is very common and occurs in about half of all people over 60 years of age. Most people do not get any symptoms.

Diverticulitis is due to inflammation of diverticula. This inflammation occurs with stasis of bowel contents in diverticula and patients can present with left iliac fossa pain, fever and altered bowel habit. Rectal bleeding can occur but not always.

Irritable bowel syndrome (IBS)

This is a common condition described as a “functional bowel disorder”, where there are intermittent problems with bowel function without underlying organic disease of the colon. This condition has a constellation of patterns and symptoms. While some consider this illness as one of the wider group of syndromes known as “Medically Unexplained Symptoms (MUS)”, the modern and more helpful approach is to make a positive diagnosis using the Rome criteria (see ELM2 Case 13: Abdominal pain). You will learn more about other syndromes of MUS in EPE 3 and throughout your career in medicine.

In Western populations IBS affects up to 1 in 5 people. It typically presents with bouts of recurrent abdominal pain, occurring at least 3 days a month for 3 months. The pain is often relieved with defecation. It is associated with changes in frequency of bowel motions, either less often or more often depending on the type. It can be also associated with a change in the appearance and form of the bowel motion. There is never blood or melaena, but mucus may be present. It is more common in women (F: M 2-3:1).

Many patients have other concurrent or intermittent functional illnesses affecting the gynaecological system, the urological system, or the musculoskeletal system.

Coeliac disease (gluten-sensitive enteropathy)

This is a condition where there is inflammation of the mucosa of the upper small bowel. This inflammation improves with removal of gluten from the diet and returns when gluten is reintroduced. The condition is caused by both genetic and environmental factors. It can present at any age. In adults the symptoms are variable. More mild disease often has non-specific symptoms that include tiredness and malaise. The patient may be anaemic. More severe disease causes diarrhoea, steatorrhoea, abdominal pain, and weight loss.

Acute hepatitis

Acute hepatitis, or acute parenchymal liver damage, has many causes. These include infection, drugs such as paracetamol, alcohol, and poisons such as carbon tetrachloride.

The patient’s symptoms will depend on the cause, but the typical presentation is with general unwellness, altered taste, nausea, and anorexia, and sometimes vomiting. The patient may have fever. The patient may become jaundiced.

Inflammatory bowel disease (IBD)

There are two major forms of Inflammatory Bowel Disease. These are:

• Crohn’s Disease (CD) - affects any part of the GI tract
• Ulcerative Colitis (UC) - affects the colon Inflammatory bowel disease (IBD) can present in people of any age. It has a peak incidence in people aged 18 and 35 years. A family history of IBD in a first-degree relative approximately doubles the lifetime risk. The major symptoms of Inflammatory bowel disease are diarrhoea, abdominal pain, and weight loss.

Inflammatory bowel disease can be associated with low energy, anorexia, nausea, vomiting and low grade fever.

Ulcerative Colitis

The peak incidence is in people aged 18-35, with a second peak in people aged 60-70. Common symptoms are bloody diarrhoea and lower abdominal discomfort. The diarrhoea can be as frequent as 20 times a day and occurs at night. The diarrhoea is often associated with urgency and faecal incontinence.

Crohn’s Disease

The peak incidence is in people aged 18-35. Common symptoms of Crohn’s Disease are diarrhoea associated with urgency and faecal incontinence, colicky abdominal pain, fatigue, and weight loss. If the disease involves the colon there will be bloody diarrhoea. Gastro-oesophageal reflux disease (GORD) GORD occurs when gastric contents reflux into the oesophagus. “Heartburn” is the major feature of GORD. It typically presents with burning chest pain worse on bending, stooping, or lying down. It seldom radiates to the arms. It is worse with hot drinks and alcohol. It is relieved by antacids. Some patients have regurgitation of food and stomach contents into the mouth.

Peptic Ulcer Disease

A peptic ulcer is caused by a breakdown in the mucosa of the lower oesophagus, stomach, or duodenum. It typically presents with recurrent burning epigastric pain. It is relieved to a degree by food or antacids. The pain of a duodenal ulcer classically occurs at night as well as during the day and may wake the patient. The pain is worse when the patient is hungry, although this is not a reliable symptom. Peptic ulceration is the most common cause of serious and life-threatening gastrointestinal bleeding. Peptic ulceration can be caused by medication such as aspirin or non-steroidal anti-inflammatory drugs. If a peptic ulcer perforates the patient presents with haematemesis and melaena. If the bleed is massive the patient will have cardiovascular compromise and can pass frank blood per rectum. There can be a past history of dyspepsia, or ulcer disease. Perforation is associated with aspirin, non- steroidal anti-inflammatory drugs, or glucocorticoid therapy such as prednisone. A perforated peptic ulcer can present as an “acute abdomen”.

Haemorrhoids

Haemorrhoids (colloquially known as piles) are swollen veins at or near the anus. They are a common cause of rectal bleeding. They may be asymptomatic but can cause bleeding, itch, and discomfort. They can prolapse and the patient may be aware of a lump protruding from the anus that they can “push back in”. They may be exacerbated by a change in bowel habit, with an episode of either diarrhoea or constipation occurring before the haemorrhoids become symptomatic. The bleeding with haemorrhoids is typically bright red, often on the toilet paper, on the outside of the bowel motion, or in the toilet bowl. Occasionally the bleeding from haemorrhoids is massive and the patient can present with a history of passing a large amount of frank blood from the rectum. The bleeding associated with haemorrhoids can be severe enough to cause iron deficiency anaemia.

Anal fissure

Anal fissures are small tears or splits in the epithelium of the anus. They can be intensely painful. They can cause rectal bleeding, with bright red blood on the toilet paper. Most anal fissures are caused due to straining during bowel movements, constipation, or repeated diarrhoea. They are equally common in both sexes, and most frequently affect people aged 15 – 40 years. . They can be associated with Crohn’s Disease. They tend to present acutely and can become chronic (lasting more than 6 weeks).

The acute abdomen

The “acute abdomen” has many causes that include inflammation, obstruction, ischaemia, perforation, or rupture. The patient with an acute abdomen may be seriously unwell and the condition can be life-threatening. The patient typically presents with acute onset severe abdominal pain. While many of the causes of an “acute abdomen” are gastrointestinal in origin other systems must be considered. These include the cardiovascular system (such as acute mesenteric ischaemia, or ruptured aortic aneurysm), the respiratory system (pneumonia presenting with acute abdominal pain), the urological/renal system (such as renal colic or pyelonephritis) and the gynaecological system (such as ruptured ectopic pregnancy or pelvic inflammatory disease). You will learn more about the presentation of the “acute abdomen” in future years. These are some of the gastrointestinal conditions that may present as an acute abdomen:

Appendicitis

A common surgical emergency affecting all age groups. Typically presents vague central abdominal pain that within hours shifts to the right iliac fossa. It is associated with nausea, vomiting, anorexia, and occasionally diarrhoea. There can be systemic symptoms of fever and fatigue. This typically presents as an “acute abdomen”.

Diverticulitis

This is due to underlying diverticulosis. Inflammation of diverticula occurs with stasis of bowel contents in diverticula and patients can present with left iliac fossa pain, fever and altered bowel habit. Rectal bleeding can occur but not always.

Gastroenteritis

This is the most common form of an acute gastrointestinal infection. It can be viral, bacterial, or protozoal in origin. It presents with colicky cramping abdominal pain and diarrhoea with or without nausea and vomiting. It can be associated with systemic symptoms including fever, headache, chills, low grade fever, muscle aches and tiredness. Dehydration with reduced or no urine output is common. As gastroenteritis can present with acute abdominal pain it may be a cause of an “acute abdomen”. Norovirus is highly contagious and is spread from one infected person to another. Campylobacter is associated with ingestion of poorly cooked food (especially chicken), and giardia is associated with ingestion of contaminated water from affected waterways.

Gallstones (cholelithiasis)

Gallstones may present at any age but are rare before the 3rd decade. They are more common in women. They may be asymptomatic but may cause biliary colic, cholecystitis, or pancreatitis.

Biliary colic

This occurs when the cystic duct or common bile duct is temporarily obstructed by a gallstone migrating from the gallbladder. The pain is in the epigastrium/right upper quadrant. It is usually a sudden onset severe constant pain that can last for up to 24 hours. It can radiate to the scapula. The pain associated with biliary colic can occur after a fatty meal, but the episodes are often unpredictable. It can be associated with nausea and vomiting. It can present as an “acute abdomen”. More protracted pain with associated systemic symptoms including fevers and rigors suggests complications such as acute cholecystitis.

Acute cholecystitis

Acute cholecystitis occurs when there is obstruction of gallbladder emptying. This is usually due to a gallstone. The gallbladder becomes increasingly distended and inflamed with compromise of blood supply. Infection occurs secondarily to the distension, inflammation, and vascular compromise. It presents initially in the same way as biliary colic but over hours there is increase in pain that is severe and localised to the right upper quadrant. Pain may radiate to the right shoulder. It is associated with systemic symptoms of fever and increasing unwellness. It is a cause of an “acute abdomen”.

Acute pancreatitis

This occurs when the pancreas becomes acutely inflamed. The most common causes are gallstones and alcohol. The patient commonly presents very unwell with anorexia, nausea, vomiting, and constant severe epigastric or upper abdominal pain. It may be associated with back pain. The patient may have a history of alcohol abuse. They may be known to have gallstones (cholelithiasis). This typically presents as an “acute abdomen”.

Perforated peptic ulcer

If a peptic ulcer perforates the patient presents with haematemesis and melaena. If the bleed is massive the patient will have cardiovascular compromise and may pass frank blood per rectum. There can be a past history of dyspepsia, or ulcer disease. Perforation is associated with aspirin, non- steroidal anti-inflammatory drugs, or glucocorticoid therapy such as prednisone. A perforated peptic ulcer can present as an “acute abdomen”.

Intestinal obstruction

This occurs when the intestine is obstructed due to a mechanical blockage. The most common cause of small intestinal obstruction in adults is adhesions. Adhesions are abnormal fibrous structures in the abdominal cavity. Surgery is the most common cause of adhesions. Adhesions can also develop in response to inflammatory diseases of the peritoneum, gut, or ovarian tubes. Colonic or large intestinal obstruction can be caused by an obstructing carcinoma of the colon. The patient typically presents as an “acute abdomen” with colicky central abdominal pain, nausea, vomiting, and constipation with no passage of flatus or wind. They may have loud borborygmi (audible bowel sounds) if there is a small intestinal obstruction. The patient may have a history of abdominal surgery.

What are the associated symptoms

Mouth ulcers

Mouth ulcers usually begin as a small painful vesicle (blister) on the tongue or mucosal surface of the mouth. They can break down to form a painful, shallow ulcer that heals well. without scarring. The most common mouth ulcer is the aphthous ulcer and the cause of these is unknown. Mouth ulcers can be associated with GI conditions such as Crohn’s Disease and Coeliac Disease.

Dysphagia

Dysphagia is the technical term for difficulty in swallowing. It can have a number of causative mechanisms such as a stricture causing a physical narrowing of a structure, a neurological problem causing muscular weakness, or pharyngitis with pain causing dysphagia.

It is important to define what the patient means by a difficulty in swallowing: • Is it difficult to swallow fluids as well as solids? • Is it painful? • Is it getting gradually worse or is it staying the same? • Is it difficult to make the swallowing movement?

Swallowing has two phases. The oropharyngeal phase is when food passes from the mouth through the hypopharynx and into the oesophagus. The oesophageal phase is when food passes through the oesophagus to the stomach.

Oropharyngeal dysphagia can cause difficulty in initiating the swallow, fluid regurgitating into the nose, and choking. This is often due to neurological disease.

Oesophageal dysphagia is caused by mechanical obstruction or a motility disorder. The patient will complain that food is sticking.

The oesophagus can be obstructed within the oesophagus by conditions such as stricture or carcinoma.

The oesophagus can be obstructed from outside the oesophagus by conditions such as a bronchial carcinoma or a retrosternal goitre.

When a patient has dysphagia, it is important to explore:

• at what phase in the swallow the dysphagia occurs
• where the patient feels the hold-up is
• when the dysphagia is occurring,
• whether the problem is with fluids or solids or both.
• associated symptoms such as:
• coughing and choking
• pain on swallowing
• heartburn or acid regurgitation
• weight loss

Indigestion / Heartburn / Dyspepsia / Gastro-oesophageal reflux

Indigestion and heartburn come under the more general term dyspepsia, which is used to describe upper gastrointestinal tract symptoms.

Indigestion commonly refers to any discomfort experienced after eating or drinking. It is important to clarify what a patient means when they tell you they have indigestion.

Heartburn is the common term for gastro-oesophageal reflux causing retrosternal burning pain that may radiate up into the throat.

The patient may also describe actual acid reflux that occurs when acid from the stomach comes up into the back of the throat. This is generally made worse on bending forward and lying flat and is also worse after alcohol and spicy or acidic foods.

Dyspepsia may not be indicative of significant underlying pathology, but it must be taken seriously in the presence of alarm symptoms.

Alarm symptoms associated with dyspepsia and gastro-oesophageal reflux:

• Pain suggestive of cardiac ischaemia with shortness of breath, and radiation to the arms and neck
• Pain radiating to the back
• Pain disrupting sleep
• Dysphagia
• Vomiting
• Gastrointestinal bleeding (haematemesis and melaena)
• Unintentional weight loss

Nausea

Nausea is the sensation of wanting to vomit or “feeling sick”. Nausea can be associated with pallor, sweating, and hyperventilation. Nausea suggests an upper abdominal problem, but medications, pregnancy, and vestibular problems may also cause it.

Retching

Retching is a strong involuntary effort to vomit with the glottis closed along with contraction of the diaphragm and abdominal muscles. Retching can occur with nausea, but the patient does not vomit.

Vomiting

Vomiting is the expulsion of gastric contents through the mouth due to sustained contraction of the abdominal muscles. It can be preceded by nausea and retching (a strong involuntary effort to vomit with the glottis closed and with contraction of the diaphragm and abdominal muscles).

It is important to ask the patient about features such as the timing of vomiting, exacerbating features and associated symptoms.

It is also important to know what the patient is vomiting. Are they bringing up undigested food, liquid, bile, or blood?

Vomiting is common in gastroenteritis, biliary colic, cholecystitis, pancreatitis, hepatitis, and intestinal obstruction.

Haematemesis

This is the medical term for vomiting blood from the upper GI tract (from Greek - haemato meaning blood and emesis meaning vomiting). The blood may be bright red if the bleeding is severe and fresh, or brown/black if it is less severe and older – this is also known as “coffee grounds” vomit.

Wind – belching/burping

Patients may use the word “wind” to mean belching, passing excessive or offensive flatus, abdominal distension, and borborygmi (audible bowel sounds). It is very important to work out what the patient means when they use the term “wind” or “flatulence”.

Belching – this is due to air swallowing and may occur when the patient tries to relieve abdominal pain. It can be associated with gastro-oesophageal reflux disease.

Melaena

Melaena is the passage of black, tarry, shiny motions. It occurs because of bleeding from the upper gastrointestinal tract and can be associated with haemetemesis. It has a characteristic odour that once smelt is always recognisable. The distinctive colour and smell is due to large amounts of blood that is altered by digestive enzymes and intestinal bacteria as it passes through the upper and lower GI tracts.

Jaundice

Jaundice is the yellowing of skin and sclerae caused by elevated plasma bilirubin. Most doctors will recognize jaundice when the bilirubin level exceeds 50mcg/l (normal range 2-20mcg/l).

Obstructive jaundice is also associated with a change in the colour of bowel motions (which become pale) and urine (which becomes dark).

Jaundice can be both a symptom that the patient notices and brings to the attention of the doctor, or a sign that is only picked up on examination if the patient has not noticed a change in their colour.

Jaundice can be associated with symptoms of abdominal pain, pruritis (skin itching), anorexia, and weight loss. The patient may have a history of infection or cholelithisasis. They may have a history of alcohol use.

Abdominal pain

Abdominal pain is a common gastroenterological symptom. SOCRATES or WWQQAA can be used to analyse this symptom:

Where/Site of pain:

• Visceral pain is deep and poorly localised centrally. It is conducted by sympathetic splanchnic nerves and is due to:
  • distension of hollow organs
  • traction on the mesentery
  • excessive smooth muscle contraction
• Somatic pain is lateralised (on one side or the other) and localised to the area of inflammation. It is conducted via the intercostal spinal nerves and is due to pathology affecting the:
  • parietal peritoneum
  • capsule of an organ
• Pain from fore-gut structures occurs above the umbilicus:
  • Stomach
  • Pancreas
  • Liver
  • Biliary system
• Pain from mid-gut structures occurs in the central abdomen:
  • small bowel
  • appendix
• Pain from a hind-gut structure occurs in the lower abdomen:
  • colon

Clinical examples of abdominal pain patterns:

• Appendicitis initially causes central abdominal pain (visceral pain). As the appendix gets more inflamed the pain becomes lateralised and localised to the right iliac fossa (somatic pain).
• Peptic ulcer disease causes pain in the epigastrium.
• Pancreatic disease causes pain in the midline, in the epigastric area or central upper abdomen, and radiates to the back.
• Biliary colic causes epigastric pain.

When/Onset

Severe pain of very sudden onset suggests the perforation of an abdominal viscus. Pain that comes on over hours or days suggests an acute inflammatory or infective process. Pain that has come on over weeks or months suggests a more chronic condition such as irritable bowel syndrome, or peptic ulcer disease.

Quality/Character

Constant pain is usually caused by inflammation. Colicky pain comes in waves. It is due to an obstructed viscus peristalsing against the obstructing lesion. It arises from hollow structures such as the smallor large intestine. Each wave lasts a short time (minutes). It builds to a peak, then subsides, and then builds to a peak again. Dull, vague, and poorly localised pain is typical of a low-grade infective process or an inflammatory process. Early appendicitis is an example of this.

Where/Radiation

• Acute cholecystitis may cause right sided shoulder pain due to diaphragmatic irritation.
• Acute pancreatitis pain may radiate to the back.

When/Timing

The pain of peptic ulcer disease typically occurs when the stomach is empty, but this is not always the case. The pain of gastro-oesophageal reflux is often worse at night when the patient lies down.

Aggravating and alleviating/Exacerbating and relieving factors

• Defecating or passing flatus can relieve the pain of irritable bowel syndrome.
• The patient with an obstructed viscus is likely to be more comfortable moving around.
• The patient with an “acute abdomen” is likely to avoid any movement. Walking, running, jumping, and even going over bumps while travelling in the car will make the pain worse.

Quantity/Severity

While a subjective assessment of pain can be made using the Pain Scale the level of severity can be assessed by finding out about the effect that pain has on the patient’s functioning.

Find out if the patient can:

• Move, walk, run, jump
• Sleep
• Eat
• Work
• Carry out usual daily activities

The pain caused by an acute abdomen due to conditions such as appendicitis, cholecystitis, or perforation is so severe that patients will be unlikely to be able to do any of these things.

The pain caused by conditions such as irritable bowel syndrome or gastro-oesophageal reflux is less severe and patients are likely to be able to do most, if not all, of these things.

Wind - Abdominal distension

Patients may use the word “wind” to mean belching, passing excessive or offensive flatus, abdominal distension, and borborygmi (audible bowel sounds). It is very important to work out what the patient means when they use the term “wind” or “flatulence”.

Abdominal distension can be due to the following causes beginning with the “F” sound:

• Fat (gross obesity – the umbilicus is usually sunken)
• Fluid (ascites – the umbilicus is flat or everted)
• Foetus (the umbilicus is flat or everted)
• Flatus (gaseous distension due to bowel obstruction)
• Faeces (colon loaded with faeces)
• “Frightfully” big tumour (abdominal mass)
• “Phantom” pregnancy

Change in normal bowel habit

This is an important gastrointestinal symptom because significant underlying bowel pathology is often accompanied by a change in normal bowel habit.

Normal bowel habit

To know if there has been a change it is essential to determine the patient’s normal bowel habit.

These are the characteristics of the patient’s normal faeces or bowel motion that you need to find out: • frequency • form • volume • colour • consistency

Once you know about the normal bowel habit you can find out about what has changed.

Be aware that patients have many and varied ways of describing their faeces or bowel motions. Many patients may never have heard the terms “stool” or “faeces” or even the word “motion”.

Find the word your patient uses and use this word in your history taking.

Normal bowel habit is extremely variable and is often reflective of the patient’s diet and lifestyle. Normal frequency ranges from three times a day to once every three days. The volume and colour is variable, often depending on the patient’s diet.

The ideal bowel motion is soft and easy to pass without straining. Passage of the normal motion is not associated with pain and the patient has a sense of complete evacuation.

Many people do not feel at all comfortable discussing their bowel habits, especially when you ask them to describe what they look like. The Bristol Stool Chart is a valuable resource as the use of pictures often enables patients to describe what is going on for them.

Altered bowel habit

When a patient notices a change in bowel habit they may refer to: • diarrhoea • constipation • rectal bleeding • change in colour • change in evacuation (emptying the rectum)

Diarrhoea

Diarrhoea refers to a marked increase in the frequency of passing faeces, that is looser or more liquid than usual. This can be due to infection such as gastroenteritis or inflammation such as inflammatory bowel disease or carcinoma.

Overflow diarrhoea

Overflow diarrhoea occurs in the severely constipated patient who complains of “diarrhoea” and often has faecal incontinence. The impacted faeces in the colon or rectum liquefies proximally and then this loose faeces leaks out as uncontrollable liquid motions.

Constipation

Constipation refers to the infrequent passage of bowel motions that are often hard and dry and difficult to evacuate. This can be quite subjective and will often depend on what is normal for the patient. For example, some people normally open their bowels three times a day, while others normally do this once every third day. The diagnosis is made easier by considering the consistency and ease of passing the motion. Constipation can be caused by medication, intestinal obstruction, and changes in diet.

Rectal bleeding

Fresh rectal bleeding suggests a disorder in the anal canal, rectum, or colon. The following questions should be considered:

1. Is the blood bright red? This suggests outlet bleeding or a massive bleed higher in the gastrointestinal tract.
2. Is the blood dark? This suggests altered blood from higher in the gastrointestinal tract. Is the blood on the outside of the motion or seen on the toilet paper after wiping? This suggests haemorrhoids or local ano-rectal disease.
3. Is the blood mixed with the bowel motion? This suggests blood from higher in the gastrointestinal tract. Causes include infection and carcinoma.
4. How much blood is there? A large amount dripping into the toilet bowel suggests bleeding from the distal colon or rectum. This can occur with haemorrhoids, carcinoma, or inflammation.

Change in colour of faeces

Steatorrhoea (pale colour)

Steatorrhoea is the passage of pale faeces containing undigested or unabsorbed lipids. The faeces are fatty, pale, foul smelling and difficult to flush away. Conditions such as pancreatic insufficiency and malabsorption can present with steatorrhoea.

Melaena (dark colour)

Melaena is the passage of black, tarry, shiny motions. It has a characteristic odour that once smelt is always recognisable. It occurs because of bleeding from the upper gastrointestinal tract. The distinctive colour and smell is due to large amounts of blood that is altered by digestive enzymes and intestinal bacteria as it passes through the GI tract.

A note about change in smell

A change in the smell of the faeces is not usually a helpful symptom. This should not be a routine question. Faeces does smell and the smell alters with the food the patient is eating. You may consider asking about this if there is a possibility of melaena and the patient has described black tarry bowel motions.

Change in evacuation (emptying the rectum)

Tenesmus

Tenesmus refers to the sensation of incomplete emptying of the bowel on defecation. Causes include a rectal tumour or inflammation of the rectum.

Faecal incontinence

Faecal incontinence is an inability to control bowel movements, resulting in involuntary passage of faeces. This is a common symptom, experienced by 10% or people at some time in their life. It is more common in the elderly, and in women. It can be due to:

• Diarrhoea
• Constipation
• Rectal pathology such as tumour
• Neurological conditions such as multiple sclerosis
• Anal sphincter injury such as 3rd degree tear with vaginal birth

Wind – excessive flatus and borborygmi

Patients may use the word “wind” to mean belching, passing excessive or offensive flatus, abdominal distension, and borborygmi (audible bowel sounds). It is very important to work out what the patient means when they use the term “wind” or “flatulence”.

Flatus – this is the passage of gas rectally. It is normal to pass 200-2000ml of flatus a day. Excessive flatus can suggest a malabsorption problem.

Borborygmi – these are audible sounds made by the GI tract. Borborygmi are colloquially known as “tummy rumbles”. Loud borborygmi if associated with colicky pain suggests a small intestinal obstruction.

Examinations

Examination

• general observation
• extra abdominal signs
  • Clubbing
  • Palmar erythema
  • tobacco staining
  • Facial pallor
  • Jaundice
  • conjunctival pallor
  • dry mouth
  • bruising or petechiae
  • scratch marks
  • spider naevi
• examining the abdomen
• inspecting the abdomen
• Palpation of the abdomen
• palpation of abdominal organs
• palpation of liver
• palpation of spleed
• percussion of the abdomen
• percussion of the liver
• percvussion of the abdomen for acities
• ausculatation of the abdomen
• gi examination
• digital rectal