Symptomatology of the

Gastrointestinal System
PROF. DR. Abdel Rahman A Mokhtar
Internist -Gastroenterologist
Mansoura University
 UPPER GI Symptoms

Eating disorders.
Salivation disorders
Painful ( soring )mouth
Breath malodorus.

Swallowing Dyspepsia.
disorders.

Nausea eructation,
Heartburn.
regurgitation & hiccough.
Abdominal
Vomiting. pain (epigastric )
Haematemsis Flatulance
 Lower GI Symptoms

Distension.
Borborygmi.

Bowel habits Act Problems :

( Diarrhoea, dysentry ,
constipation and tenesmus)
Dyschezia
Difficult act.
Stool Character Proctodynia
Melena , hematochezia ,
passing warms. Painful act
Symptoms related to the GI Adenexae

Hepatocellular
dcompensation

Vascular Cholestasis S
decompensation
 Disorders of appetite
Increased appetite: Decreased appetite:
1. Emotional disturbance,
anorexia nervosa
1. DM (amenorrhea)
2. Thyrotoxicosis
3. Parasitic infestation 2. Gastric diseases like
acute/chronic gastritis,
4. Malabsorption atrophic gastritis, cancer
5. Pregnancy stomach

3. Metabolic chronic renal

failure, liver cell failure
Weight loss occurs in most of these
Conditions secondary to loss of energy 4. Chronic infection T.B,
(increased energy expenditure) chronic inflammation,
From uncontrolled glycosuria malignancy
hyperthyroidism
 SPECIFIC SYNDROMES OF EATING DISORDERS
Anorexia nervosa (AN), characterized by
refusal to maintain a healthy body weight and an
obsessive fear of gaining weight.

Bulimia nervosa (BN), characterized by recurrent binge

eating followed by compensatory behaviors such as
purging (self-induced vomiting, excessive use of
laxatives/diuretics, or excessive exercise) Bulimics may
also fast for a certain amount of time following a binge.
Binge eating disorder (BED) or compulsive overeating,
characterized by binge eating, without compensatory
behavior.

Pica, characterized by a compulsive craving for eating,

chewing or licking non-food items or foods containing no
nutrition. These can include such things as chalk, paper,
plaster, paint chips, baking soda, starch, glue, rust, ice,
coffee grounds, and cigarette ashes.
Ptyalism
APTYALISM
 Painful mouth (Mouth Ulcers)

Causes of sore lips, tongue, buccal mucosa include

Iron, folate, vitamin B12 deficiency

Aphthous ulcers (recurrent painful tiny ulcers)

Infective stomatitis (candidiasis)

Inflammatory bowel disease

Celiac disease
Collagen vascular diseases SLE
 HALITOSIS Oral Malodor
Food (onions, Poor dental hygiene; Association with H.Pylori
garlic). gingivitis, periodontitis, Pharyngeal pouch
dentures. Gastric outlet problems
Drugs: ISDN, Severe Reflux
disulfaram.
PN drip, sinusitis, nasal
polyps, adenoids, foreign DKA
Xerostomia: anxiety, Renal dysfunction
pyrexia, bodies, tonsillitis &
anticholinergics, tonsilliths. Hepatic dysfunction
antihistamines,
Sjgrens Syndrome.
Naso-oropharyngeal mal. Respiratory disease

Delusional halitosis

Hallucinatory feature of psychotic illness

Temporal Lobe Epilepsy

 WHERE DOES IT COME FROM ?

85-90% comes from the mouth itself.

Formed by bacterial putrefaction of food debris,
cells, saliva and blood.
Proteolysis of proteins peptides aminoacids
free thiol groups & volatile sulphides.
Results from any form of sepsis : increased anaerobic
activity of pathogens (inc. Treponema denticola,
P.Gingivalis and Bacteroides forsythus).
Despite rigorous hygiene, good dentition, posterior
dorsum of tongue is often a source (? Post nasal drip
related).
DYSPHAGIA difficulty of swallowing

Dysphagia caused:

By narrowed lumen: mechanical dysphagia

By impaired contraction, inhibition and sphincter relaxation:
motor dysphagia
 Dysphagia
Oropharyngeal Esophageal
Structural Structural (solids)
Cervical osteophytes Diverticulum
Cricoid webs Strictures
Neurologic Webs/rings
CNS tumor Neoplasm (Red Flags)
CVA Motility (solids/liquids)
Myasthenia gravis Achalasia
Parkinsons DES
Scleroderma

Videofluorocopy swallow study EGD then Esophageal manometry

The patient : Historical considerations
young maleeosinophilic oesophagitis.
>40 years mostly due to Schatzki ring.
>50 years of age consider oesophagcancer
The Dysphagia: Q.3 Associated symptoms ?
Previous history of heartburn is
Q2.Is the dysphagia suggestive of peptic stricture.
intermittent or
Q1.To what kind of food Diifficulty initiating a swallow along
progressive?
(i.e., liquid or solid)? with coughing, choking, hoarseness,
Rapid progression of
Early to solids = gagging, and nasal regurgitation is
dysphagia, particularly more suggestive of oropharyngeal
Mechanical dysphagia (
with weight loss, is dysphagia
structural ) , later to
suggestive for
both. Laryngeal symptoms and dysphagia
malignancy
occurs in various neuromuscular
disorders
Early to both solids
Oesophageal rings tend
and liquids = Motor Hoarseness precedes dysphagia: the
to cause intermittent primary lesion is usually in the larynx
dysphagia due to neuro
solid food dysphagia
or motility disorder e.g Hoarseness following dysphagia
achalasia . suggests involvement of the
peptic strictures usually reccurent laryngeal nerve by
have long-standing extension of esophageal cancer
history of dysphagia. Painful swallowing (odynophagia)
suggest candidal, herpes, or pill-
induced esophagitis
Investigations
Barium esophagogram or upper endoscopy?
* Upper endoscopy is the initial investigation of choice in patients with esophageal
dysphagia as it can be both diagnostic and therapeutic.

* Barium evaluation may be more sensitive than routine endoscopy in detecting subtle
esophageal narrowing caused by mucosal rings and is recommended as the primary test
when there is a high suspicion for achalasia or proximal esophageal lesions.

If the upper endoscopic and barium examinations are normal,

Esophageal biopsy examinations mid & distal _ ( The diagnosis of eosinophilic esophagitis is
based on the presence of >/= 20 eosinophils per high-power field. Patients with reflux esophagitis
rarely have > 5-10 eosinophils per high-power field ) , as well as esophageal manometry, may be
indicated.
* Video swallow examination is a technique which allows video recording of the patient
swallowing barium mixed solids of varying consistencies as well as liquids: with special attention to
the pharyngeal phase of swallowing. This would be the first investigation of choice in patients with
history suggestive of disordered oropharyngeal phase of swallowing
 Odynophagia

Pain on swallowing often precipitated by hot liquids

Indicates active esophageal ulceration from peptic

esophagitis or candidiasis

It indicates intact mucosal sensation making malignancy unlikely

 Nausea ,
Retching ,
Vomiting ,
& Regurgitation
 1
Understanding terms?

It is important to distinguish between the various symptoms that may be

related to vomiting.

Nausea is the unpleasant sensation of being about to vomit and is often associated with
mouth watering.

Vomiting is the forceful expulsion of gastric contents via the mouth.

Retching is contraction of the abdominal muscles without the expulsion of gastric contents.

Regurgitation is the effortless appearance of gastric contents into the

mouth, usually without nausea, and may be a symptom of gastro-oesophageal reflux disease or
rumination syndrome
2 Pathophysiology of vomiting?
3
Causes of
vomiting? `
 ABCDEFGHI
A ..Acute RF .. Addison disease
B ..Brain eg increase ICT.
C . Cardiac eg AMI
D Diabetic ketoacidosis
E Ears e.g Labrynthitis , Meniers disease
F Foreign substances e.g alcohol , drugs , opiates.
G Gravidity eg hyper emesis gravidarum.
H .. Hypercalcemia , hyponatraemia.
I Infection eg , UTI , Meningitis.
Medications that often cause nausea
and vomiting
Cancer chemotherapy Metformin
e.g. cisplatin
Anti-parkinsonians
Analgesics e.g., bromcryptine, L-DOPA
e.g. opiates, NSAIDs
Anti-convulsants
Anti-arrythmics e.g., phenytoin, carbamazepine
e.g., digoxin, quinidine
Anti-hypertensives
Antibiotics
e.g., erythromycin
Theophylline
Oral contraceptives Anesthetic agents
 Less commonly recognized causes
of nausea and vomiting
Rapid weight loss/
body casts (SMA syndrome)
Infectious esophagitis
esp. if immunocompromised
Opiate withdrawal
Herbal preparations
Pregnancy
nausea of early pregnancy
hyperemesis gravidarum
AFLP/ HELLP syndrome
 Complications of Vomiting
Nutritional
adults: weight loss; kids: failure to gain
Cutaneous (petechia, purpura)
Orophayngeal (dental, sore throat)
Esophagitis/ esophageal hematoma
GE Junctional: M-W tears; rupture (Boorhaaves)
Metabolic: electrolyte, acid-base, water
Renal: prerenal azotemia; ATN; hypokalemic
nephropathy
 Electrolyte and acid-base
disorders due to vomiting
Metabolic alkalosis
retention of HCO3- + volume-
contraction
Hypokalemia
renal K+ losses + GI K+ loss +
oral K+ intake
Hypochloremia
gastric chloride losses
Pearl: Patients with uremia
Hyponatremia
or Addisons disease may
free water retention due to have normal or even high
volume contraction serum K+ despite vomiting
 Nausea and Vomiting:
Key Historical Questions
The content of vomitus
Food residue ingested hours or days previously gastroparesis, pyloric stenosis
Feculent emesis (miserere) distal intestinal or colonic obstruction
Emesis of undigested food achalasia, oesophagus diverticuli
Hematemesis ulcer, malignancy, Mallory-Weiss syndrome, rupture of oesophageal
varices.
The effect of the emesis
Relief the abdominal pain small-bowel obstruction
No effect on the pain pancraetitis, cholecystitis
Timing of the vomitus
Immediatly after eating psychogenic cause
In the morning hyperemesis gravidarum
Within 1 h of eating pyloric obstruction or gastroparesis
2-3 h or later after eating ulcer disease, intestinal obstruction
Associated symptoms
pain in chest or abdomen, fever, myalgias, diarrhea, vertigo, dizziness, headache, focal
neurological symptoms, jaundice, weight loss
When was last menstrual period?
HAEMATEMSIS
 Upper GI bleeding
Bleeding proximal to the ligament of trietze
The ligament of
Treitz is a
musculofibrous band that
extends from the upper
aspect of the ascending
part of the duodenum to
the right crus of the
diaphragm and tissue
around the celiac artery.

Ligament of
Treitz
Bleeding proximal to the ligament of trietze
 Presentation
Haematemesis
Malena
Melena:
passage of black
Haematochezia Tarry offensive stool due to
Anemia Bleeding from the upper
GIT proximal to ligament of
Fecal Occult Blood
Tretiz ( > 100 ml).
 Assessment of the blood loss
Estimated fluid and blood losses for 70 kg man
Source Resuscitation council/UK

CLASS 1 CLASS 2 CLASS 3 CLASS 4

Blood loss 750 750-1500 1500-2000 >2000

-15% 25-30% 30-40% >40%

Pulse rate <100 >100 >120 >140

BP N N D D

Pulse pressure N D D D

RR 14-20 20-30 30-40 >35

UOP >30 20-30 5-15 Negligible

CNS/MENTAL Slightly Mildly Anx/conf Conf/leth

Anxious Anx

Fluid replacement Crystalloid Crystalloid Cryst/blood Cryst/blood

 Gastroscopy
Endoscopy should be done within 24 H
Adrenaline injection
Heat probe
Argon plasma coagulation
 Surgery
For uncontrollable bleeding by endoscopy
(Severe upper GIT bleeding)
Large esophageal varices
Gastritis produced by aspirin and other
nonsteroidal anti-inflammatory drugs
Benign gastric ulcer
Duodenal ulcer
Cardia carcinoma
Heartburn (reflux symptoms)

Heartburn is a hot burning retrosternal

discomfort which radiates upwards

Diagnostic of GERD

Regurgitation of acid producing a sour

taste in the mouth called acid reflux

Increase with bending forward or lying

flat

Those differentiate GERD from angina

 Dyspepsia

Dyspepsia is pain or discomfort centered in

the upper abdomen and related to meals.

Dyspepsia affects up to 80% of population at

some time

Reflux like dyspepsia (heartburn predominant)

Ulcer like dyspepsia (epigastric pain relieved by
antacids)
Dysmotility like dyspepsia (nausea, belching, bloating,
premature satiety)
Fat intolerance ( fat dyspepsia ) is common with
gallbladder disease
Abdominal Pain
 Vital Questions :
Intra-abdominal vs Abdominal wall pain

intra- abdominal pain

Visceral , Parietal vs, Refered

Considering the pathologic nature

Inflammatory , Obstructive , Ischemic ,Perforation

Most Probable Cause

Medical , Surgical or Gynaecologic
 Abdominal pain

Quality - What is the pain like?

Location - Where is the pain ?
Radiation - Does it radiate?
Timing Did it start suddenly or gradually?
Connection - Reference to eating - Is any connection
with the eating?
What aggravates or relieves the pain?
What symptoms are associated with the pain?
 History Taking in Abdominal Pain
Presentations
OLD CARS P Medical H
Similar episodes in past
Other medical problems that
increase disease likelihood of
O- onset problems (ex: DM and
gastroparesis)
L- location
P Surgical H
D- duration Adhesions, hernias, tumors
C- character Drug H
Abx, NSAIDS, acid blockers,
A-alleviating/aggravating etc
factors GYN/URO
associated symptoms LMP, bleeding, discharge
Social
R- radiation Tob/EtoH/drugs/home
S- severity situation/agenda
 Vital Questions :
Intra-abdominal vs Abdominal wall pain

intra- abdominal pain

Visceral , Parietal vs, Refered

Considering the pathologic nature

Inflammatory , Obstructive , Ischemic ,Perforation

Most Probable Cause

Medical , Surgical or Gynaecologic
 Rule Out
CAWP :
Chronic abdominal wall
pain syndrome.
Pathophysiology of CAWP

Myofascial pain and

radiculopathy are rare
examples
of a CAWP syndrome.

However, CAWP is
commonly caused by
the entrapment of an
anterior cutaneous
branch of one or more
thoracic intercostal
nerves.
 Pathophysiology of ACNES :
The thoracoabdominal nerves, which terminate as the cutaneous nerves, are
anchored at six points :

1) The spinal cord;

2) The point of the posterior branch origin .

3) the point at which the lateral branch originates.

4) the point at which the anterior branch makes

a nearly 90 turn to enter the rectus channel;

5) the point from which accessory branches are

given off in the rectus channel.

6) skin.
CLINICAL PRESENTATION
General features of musculoskeletal abdominal wall pain
 Vital Questions :
Intra-abdominal vs Abdominal wall pain

intra- abdominal pain

Visceral , Parietal vs, Refered

Considering the pathologic nature

Inflammatory , Obstructive , Ischemic ,Perforation

Most Probable Cause

Medical , Surgical or Gynaecologic
 Look For
The Pattern of :
Intra-abdominal pain

Visceral. -Gut organs are insensitive to stimuli such as burning

and cutting but are sensitive to distension, contraction, torsion
and stretching.
Parietal. -The parietal peritoneum is innervated by somatic
nerves, and its involvement by disease e.g. inflammation,
infection or neoplasia, causes sharp, well-localised and lateralised
pain.
Referred pain. -(For example, gallbladder pain is referred to
the back or shoulder tip.)
Psychogenic. -Cultural, emotional and psychosocial factors
influence everyone's experience of pain (depression or
somatisation disorder)
The Pattern of Abdominal Pain
Visceral pain The visceral peritoneum is innervated by C fibers,
which are slow transmitters.
These fibers produce dull, crampy pain, usually of
Hollow viscus distention insidious onset and poorly localized.
Solid organs capsule stretch
Difficult to localize .
Due to the relatively sparse innervation of the viscera, patients are often unable to
localize their pain.
There are three types of visceral pain:
Tensionoften colicky owing to increased force of peristalsis
Inflammatorylocalized due to involvement of the parietal peritoneum, as in Appendicitis
Ischemicsudden, intense, progressive, and unrelieved by analgesics

Parietal pain
The parietal peritoneum, skin, and muscles are innervated by the fast transmitting A -
neurons which result in sharp pain, often of acute onset and well localized
So Inflammation of the parietal peritoneum is more sever, localized
Referred pain
Distant sites & Same spinal nerves as the disordered structures
The site of Abdominal pain

Stomach, Duodenum, pancreas

Small intestine, appendix,

proximal colon

Colon, rectum, bladder, uterus

The site of
Abdominal
pain
 Vital Questions :
Intra-abdominal vs Abdominal wall pain

intra- abdominal pain

Visceral , Parietal vs, Refered

Considering the pathologic nature

Inflammatory , Obstructive , Ischemic ,Perforation

Most Probable Cause

Medical , Surgical or Gynaecologic
Considering analysis of the pain course , nature and localisation
( Surgical causes) :
UsuallyLesion
acute
Inflammation Acute mesenteric
Perforated
Location
Organ
ischemia
PU
Lesion
occlusion of the SMA
from thrombus or
Small Bowel Adhesions
Stomach
Obstruction embolism
Gastric Ulcer
Perforated diverticular Hernia
disease
Duodenal Ulcer
Cancer
Crohns disease
Obstruction Biliary Tract AcuteGallstone
cholecystitisileus
Chronic mesenteric AcuteTypically
cholangitis smoker,
Perforated appendix Intussusception
ischemia vasculopathy with
Volvulus
severe atherosclerotic
Pancreas Acute,vessel disease
recurrent, or chronic
pancreatitis
Acute chlolecystitis with Perforation
Ischemia Large Bowel
Obstruction
Malignancy
Volvulus: cecal or
Small Intestine sigmoid
Crohns disease
Diverticulitis
Meckels diverticulum
Ruptured AAA
Ischemic colitis
Perforation Biliary colic
Large Intestine Appendicitis
Ureteric colic
Perforated bladder
(any of above can end here) Diverticulitis
Torsion of a viscus
Acute retention
 D.D : Medical Causes
System Disease System Disease
Cardiac Myocardial infarx Endocrine Diab ketoacidosis
Acute pericarditis Addisonian crisis

Pulmonary Pneumonia Metabolic Acute porphyria

Pulmonary infarx Mediterranean fever
PE Hyperlipidemia

GI Acute pancreatitis Musculo- Rectus muscle

Gastroenteritis skeletal hematoma
Acute hepatitis

GU Pyelonephritis CNS Tabes dorsalis (syph)

PNS Nerve root
compression

Vascular Aortic dissection Hematological Sickle cell crisis

 D.D : GYN Causes

Organ Lesion
Ovary Torsion of ovary
Ruptured graafian follicle
Tubo-ovarian abscess (TOA)

Fallopian tube Ectopic pregnancy

Acute salpingitis
Pyosalpinx

Uterus Uterine rupture

Endometritis
Attention, Attention , Attention
 Lower GI Symptoms

Distension.
Borborygmi.

Bowel habits Act Problems :

( Diarrhoea, dysentry ,
constipation and tenesmus)
Dyschezia
Difficult act.
Stool Character Proctodynia
Melena , hematochezia ,
passing warms. Painful act
 Abdominal distension
Increased abdominal girth

Fat: slow increase over months/years

Flatus: belching, abdominal distension, audible

intestinal sounds (swallowing of air and colonic
bacterial fermentation from poorly absorbed
carbohydrates)

Faeces: subacute obstruction, constipation

Fetus: Pregnancy

Functional: Bloating with IBS

Fluid: ascities, tumor (ovarian masses)

 Flatulence (meteorism) - abdominal
swelling
Increased gas
Aerophagia
Consumption of legumes (pease, bean, lentil)
Bacterial fermentation of unabsorbed carbohydrates
(lactase deficiency)
Decreased absorption of gases across the bowel wall
(congestive heart failure, portal congestion in cirrhotic
patients)
Inhibited evacuation (mechanic or paralytic ileus).
Increased parasympathetic activity
Physical signs
Diffuse protuberance of the abdomen, tightening,
tympanic percussion sound.
 Borborygmi

Excessively noisy bowel peristalsis

Gut obstruction (pain, constipation, vomiting)
Gastroenteritis (diarrhoea, nausea, pain)
Food poisoning
Toxic enteritis
Excess swallowed air (rapid eating, nervous
swallowing)
Aerated drinks
 The bowel
frequency of the
In the normal state, normal
approximately 10 L of fluid enter population
the duodenum daily, of which all ranges from three
but 1.5 L are absorbed by the
bowel movements
small intestine.
per day to one
bowel action
every third day,
The colon absorbs most of the and a normal
remaining fluid, with only 100 mL lost in stool consistency
the stool. ranges from
From a medical standpoint, diarrhea is porridge-like to
defined as a stool weight of more than hard and pellety.
250 g/24 h
 Diarrhea
The passage of abnormally liquid or unformed stools
at an increased frequency. The stool weight is more
than 250 g/day.
Pseudodiarrhea: The frequent passage of small volumes of
stool (rectal urgencies, IBD, proctitis)
Fecal incontinence: involuntary discharge of rectal
contents, is most often caused by neuromuscular disorders
or structural anorectal problems.
Overflow diarrhea: In elderly patients due to fecal
impaction that is detectable by rectal examination.
More than 250 gms ?
Increased volume ?
Hard to quantify

Increased frequency ?
Diarrhoea as a symptom :
Some individuals have Is described as frequent bowel
increased fecal weight due to evacuation or the passage of
fiber ingestion but do not abnormally soft or liquid faeces.
complain of diarrhea because Diarrhoea as a sign: Is
their stool consistency is increase in stool volume more
normal. than 250 gm per 24 hrs.

Conversely, other patients Acute lasts less than 7 - 14 days

have normal stool weights but Chronic lasts more than 2 - 3 weeks
complain of diarrhea because
their stools are loose or watery
Tenesmus ?
Constipation
 Causes
Inadequate fluid or fiber Structural disorders
intake Rectal prolapse, stricture, fissure,
Suppression of defecatory abscess
urge Colonic mass, stricture
Hirschsprung disease
IBS
Systemic disease
Impaired colonic motility
Hypothyroidism
Drugs- opioids, CCB, Iron, Hyperparathyroidism
calcium, anticholenergics Hypokalemia
Parkinsons, paraplegia
Autonomic neuropathy
Symptoms related to the GI Adenexae

Hepatocellular
dcompensation

Vascular Cholestasis S
decompensation
Hepatocellular
dcompensation
 History taking

Jaundice
Important anamnestic factors
Color of the skin: overproduction: lemon
obstructive: dark-yellow,
greenish
Color of the stool: overproduction: dark, greenish
(pleiochromic)
obstructive: hypocholic, acholic
Color of the urine: overproduction: cherry-red
obstructive: dark, brown
Associated symptoms: anemia, pain, fever, hepatomegaly,
splenomegaly, ascites
Cholestasis S