This document provides information on evaluating gastrointestinal (GIT) symptoms and complaints. It begins by outlining the steps to take in a GIT history, including collecting personal data, details of main complaints, and reviewing other symptoms. It then discusses analyzing the main complaints in more detail and performing a systemic review. Various GIT symptoms such as anorexia, weight loss, and abdominal pain are also defined. Pain characteristics like location, onset, character, radiation, timing, exacerbating/relieving factors and severity are examined to help determine potential causes.

1. GIT History
Dr Kamal Mahmoud

2. History of the GIT
• Start as usual:
• Introduce yourself
• Ask consent

3. • Start with the personal data
• Then the main complaints
• Then analyze the main complaints

4. Analysis of the main complaints
• In the analysis of the main complaints:
• Detail the complaints
• Ask about other symptoms of the involved system
• Ask about general symptoms: fever , wt loss and anorexia
• Ask if there are similar attacks before
• If related to a specific chronic disease ask about it and report it here

5. • Systemic review
• Past history
• Family history
• Drug history
• Social history
• summary

6. GIT symptoms
Symptoms and definition:
Anorexia and weight loss
Pain
Dysphagia
Nausea and vomiting
Wind and flatulence
Abdominal distension
Altered bowel habit
Bleeding
Jaundice

7. Anorexia
Anorexia is loss of appetite and/or a lack of interest in food

8. Weight loss
Weight loss is usually the result of reduced energy intake, not
increased energy expenditure (Box 8.3).

9. Reduced energy intake arises from dieting, loss of appetite or
malabsorption and malnutrition. Energy loss occurs in
uncontrolled diabetes mellitus due to marked glycosuria.
Increased energy expenditure occurs in hyperthyroidism, fever or
the adoption of a more energetic lifestyle.

10. A net calorie defcit of 1000 kcal/day produces a weight loss of
approximately 1 kg/week (7000 kcal ≈ 1 kg of fat). Greater weight
loss during the initial stages of energy restriction arises from salt
and
water loss and depletion of hepatic glycogen stores, and not from
fat loss.
Rapid weight loss over days suggests loss of body fluid as a
result of vomiting, diarrhoea or diuretic therapy (1 litre of water =
1 kg).

11. Weight loss, in isolation, is rarely associated with serious organic
disease and loss of <3 kg in the previous 6 months is rarely
signifcant.
It does not specifically indicate gastrointestinal disease but is
common in many upper gastrointestinal disorders, including
malignancy
and liver disease.
Weight loss with amenorrhoea in an adolescent female may
suggest anorexia nervosa but menstrual irregularity is common in
women who lose weight from any cause.

13. Heartburn and reflux
Heartburn is a hot, burning retrosternal discomfort which radiates
upwards. When heartburn is the principal symptom, gastro
oesophageal reflux disease (GORD) is the likeliest diagnosis.

14. A sour taste in the mouth from regurgitating gastric acid is called
reflux. Differentiate heartburn from cardiac chest pain by its
burning quality, upward radiation, association with acid reflux and
its occurrence on lying flat or bending forward.
Waterbrash is the sudden appearance of fluid in the mouth due to
reflex salivation as a result of GORD or, rarely, peptic ulcer
disease.

15. Dyspepsia
Dyspepsia is pain or discomfort centred in the upper abdomen.
Dyspepsia affects up to 80% of the population at some time. In
the majority, no identifable cause is found (functional dyspepsia).

16. Clusters of symptoms are used to classify dyspepsia:
• reflux-like dyspepsia (heartburn-predominant dyspepsia)
• ulcer-like dyspepsia (epigastric pain relieved by food or
antacids)
• dysmotility-like dyspepsia (nausea, belching, bloating and
premature satiety).

17. There is considerable overlap and it is impossible to diagnose
functional dyspepsia on history alone, without investigation.
Dyspepsia that is worse with an empty stomach and eased by
eating is the classical symptom of peptic ulceration. The patient
may indicate a single localised point in the epigastrium (pointing
sign), and complain of nausea and abdominal fullness which is
worse after meals with a high spice or fat content. ‘Fat
intolerance’ is common in all causes of dyspepsia, including
gallbladder disease.

18. Odynophagia
Odynophagia is pain on swallowing, often precipitated by drinking
hot liquids. It can be present with or without dysphagia and may
indicate active oesophageal ulceration from peptic oesophagitis
or oesophageal
candidiasis. It implies intact mucosal sensation, making
oesophageal cancer unlikely.

19. Abdominal pain
Site
Visceral abdominal pain from:
distension of hollow organs
mesenteric traction
or excessive smooth-muscle contraction is deep and poorly
localised in the midline.
It is conducted via sympathetic splanchnic nerves.

20. Somatic pain
Somatic pain from the parietal peritoneum and abdominal wall is
lateralised and localised to the area of inflammation. It is
conducted via intercostal (spinal) nerves.

21. Pain arising from foregut structures (stomach, pancreas, liver and
biliary system) is localised above the umbilicus (Fig. 8.5).
Central abdominal pain arises from midgut structures, e.g. small
bowel and appendix.
Lower abdominal pain arises from hindgut structures, e.g. colon.
Inflammation may cause localised pain, e.g. left iliac fossa pain
due to diverticular disease of the sigmoid colon

23. Pain from an unpaired structure, such as the pancreas, is midline
and radiates through to the back. Pain from paired structures is
felt on and radiates to the affected side, e.g. renal colic.
Boys with abdominal pain may have torsion of the testis (Fig.
10.51).
In women, consider gynaecological causes, e.g. ruptured
ovarian cyst,
pelvic inflammatory disease, endometriosis or an ectopic
pregnancy.

24. Onset
The sudden onset of severe abdominal pain, rapidly progressing
to become generalised and constant, suggests a hollow viscus
perforation, a ruptured abdominal aortic aneurysm or mesenteric
infarction.

25. Preceding constipation suggests colorectal cancer or diverticular
disease as the cause of perforation and prior dyspepsia suggests
peptic ulceration.
Coexisting peripheral vascular disease, hypertension, heart
failure or atrial fbrillation may suggest aortic aneurysm or
mesenteric ischaemia.

26. Development of circulatory failure following the onset of pain
suggests intra-abdominal sepsis or bleeding, e.g. ruptured aortic
aneurysm or ectopic pregnancy.
Torsion of the testis or ovary produces severe acute abdominal
pain and nausea.
Torsion of the caecum or sigmoid colon (volvulus) presents with
sudden abdominal pain associated with acute intestinal
obstruction.

27. Character
Inflammation and obstruction are the principal pathological
processes producing acute abdominal pain. Inflammation usually
produces constant pain

28. Colicky pain
Due to obstruction of a hollow muscle tube

29. Dull pain
That is poorly localized is a feature of inflammatory pain : appendicitis

30. Radiation
Right HC ( of cholecystitis ) that radiates to the right shoulder is due to
diaphragmatic irritation by the inflamed GB.
Why diaphragmatic irritation causes shoulder pain?

31. Pain radiating from the loin to groin and genitalia suggests renal colic.

32. Central abdominal pain radiating through the back ,partially releaved
by leaning forward is typical of pancreatitis

33. Central abdominal pain that shifts to the right IF is typical of
appendicitis

34. Severe abd pain and backache may suggest a ruptured AA.

35. Associated symptoms

36. Timing
During the frst hour or two after perforation, a ‘silent interval’ may
occur when abdominal pain resolves transiently. The initial
chemical peritonitis may subside before bacterial peritonitis
becomes established.

37. In acute appendicitis, pain is initially periumbilical (visceral pain)
and moves to the right iliac fossa when localized inflammation of
the parietal peritoneum becomes established (somatic pain). If
the appendix ruptures, generalised peritonitis may develop.
Occasionally, a localized appendix abscess develops, with a
palpable mass and localised pain in the right iliac fossa.

38. Change in the pattern of symptoms suggests either that the initial
diagnosis was wrong, or that complications have developed. In
acute small-bowel obstruction, a change from typical intestinal
colic to persistent pain with abdominal tenderness suggests
intestinal ischaemia, e.g. strangulated hernia, an indication for
urgent surgical intervention.

39. Exacerbating and relieving factors
Pain exacerbated by movement or coughing suggests
inflammation. Patients tend to lie still in order not to exacerbate
the pain. Patients with colic typically move around or draw their
knees up towards the chest during painful spasms. Abdominal
pain persisting for hours or
days suggests an inflammatory disorder, such as acute
appendicitis, cholecystitis or diverticulitis

40. Severity
Excruciating pain, poorly relieved by opioid analgesia, suggests
an ischaemic vascular event, e.g. bowel infarction or ruptured
abdominal aortic aneurysm.
Severe pain rapidly eased by potent analgesia is more typical of
acute pancreatitis or peritonitis secondary to a ruptured viscus