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

Distension.
Borborygmi.

Bowel habits Act Problems :

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

Hepatocellular
dcompensation

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

3. Metabolic chronic renal failure,

Weight loss occurs in most of these
Conditions secondary to loss of energy
(increased energy expenditure)
From uncontrolled glycosuria
hyperthyroidism
liver cell failure
4. Chronic infection T.B, chronic
inflammation, malignancy
 “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, garlic). Poor dental hygiene; Association with H.Pylori
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,
Sjögren’s 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
• Esophageal
Oropharyngeal
– Structural (solids)
• Diverticulum
Cervical osteophytes
• Strictures
Cricoid webs
• Webs/rings
– Neurologic
•• Neoplasm
CNS tumor(Red Flags)
– Motility
• CVA (solids/liquids)
• Myasthenia
Achalasia gravis
• DES
Parkinson’s
• Scleroderma
Videofluorocopy “swallow study” EGD then Esophageal manometry
 Historical considerations
The patient :
young male…eosinophilic oesophagitis.
>40 years mostly due to Schatzki ring.
>50 years of age cons ider oes ophagcancer
The Dysphagia:

Q.3 Associated symptoms ?

Previous history of heartburn is
Q2.Is the dysphagia suggestive of peptic stricture.
Q1.To what kind of food intermittent or
(i.e., liquid or solid)? progressive? Diifficulty initiating a swallow along
Early to solids = Rapid progression of with coughing, choking, hoarseness,
dysphagia, particularly gagging, and nasal regurgitation is
Mechanical dysphagia
more suggestive of oropharyngeal
( structural ) , later to with weight loss, is dysphagia
both. suggestive for
malignancy Laryngeal symptoms and dysphagia
occurs in various neuromuscular
• Early to both solids disorders
and liquids = Motor Oesophageal rings tend
to cause intermittent Hoarseness precedes dysphagia: the
dysphagia due to primary lesion is usually in the larynx
neuro or motility solid food dysphagia
disorder e.g Hoarseness following dysphagia
suggests involvement of the
achalasia . 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
• Metformin
Cancer chemotherapy
– 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
• Theophylline
– e.g., erythromycin

• 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 (Boorhaave’s)
• 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
Hyponatremia Pearl: Patients with uremia
or Addison’s 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:
• Haematochezia passage of black
Tarry offensive stool due to
• Anemia
Bleeding from the upper
• Fecal Occult Blood
GIT proximal to ligament of
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
– L- location gastroparesis)
• P Surgical H
– D- duration – Adhesions, hernias, tumors
– C- character • Drug H
– A-alleviating/aggravating – Abx, NSAIDS, acid blockers, etc
factors • GYN/URO
– LMP, bleeding, discharge
associated symptoms • Social
– R- radiation – Tob/EtoH/drugs/home
situation/agenda
– S- severity
 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

;The spinal cord )1

. The point of the posterior branch origin )2

.the point at which the lateral branch originates )3

the point at which the anterior branch makes )4

;a nearly 90° turn to enter the rectus channel

the point from which accessory branches are )5

.given off in the rectus channel

.skin )6
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.
Hollow viscus distention These fibers produce dull, crampy pain, usually of
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:

Tension—often colicky owing to increased force of peristalsis

Inflammatory—localized due to involvement of the parietal peritoneum, as in Appendicitis
Ischemic—sudden, 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 (
Perforated
Acute Location
PU
mesenteric UsuallyLesion
acute
Inflammation Organ
ischemia Lesion
occlusion of the SMA
from thrombus or
Adhesions
Small Bowel
Stomach
Obstruction embolism
Gastric Ulcer
Perforated diverticular Hernia
disease
Duodenal Ulcer
Cancer
Crohn’s disease
Obstruction Biliary Tract
Chronic mesenteric
AcuteGallstone
cholecystitisileus
AcuteIntussusception
cholangitis smoker,
Typically
Perforated
ischemia appendix 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
Crohn’s disease
Diverticulitis
Meckel’s diverticulum
Ruptured AAA
Ischemic colitis
Perforation Biliary colic
Large Intestine Appendicitis
Ureteric colic
Perforated bladderDiverticulitis
)any of above can end here(
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

s e d
n o
ia g
i sd
n M
fte
O
Lower GI Symptoms

Distension.
Borborygmi.

Bowel habits Act Problems :

( Diarrhoea, dysentry ,
constipation and tenesmus)
Dyschezia Difficult
act.
Stool Character
Melena , hematochezia , Proctodynia Painful
passing warms. 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
 Diarrhea can be defined by
increased stool
frequency, liquidity, or volume.
Healthcare professionals typically
think of diarrhea as an increase in
stool frequency1;

The bowel
In the normal state, frequency of the
approximately 10 L of fluid enter normal 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, and a
The colon absorbs most of the normal stool
remaining fluid, with only 100 mL lost in consistency ranges
the stool. from porridge-like
From a medical standpoint, diarrhea is to hard and pellety.
defined as a stool weight of more than
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 increased Is described as frequent bowel evacuation or the
fecal weight due to fiber ingestion passage of abnormally soft or liquid faeces.
but do not complain of diarrhea
• Diarrhoea as a sign: Is increase in stool volume
because their stool consistency is
more than 250 gm per 24 hrs.
normal.

Conversely, other patients have

normal stool weights but complain of Acute lasts less than 7 - 14 days
diarrhea because their stools are Chronic lasts more than 2 - 3 weeks
loose or watery
Tenesmus ?
Constipation
 Causes
• Structural disorders
Inadequate fluid or fiber intake
• Rectal prolapse,ofstricture,
Suppression fissure,
defecatory abscess
urge
• Colonic
IBS mass, stricture
 Hirschsprung disease
• Impaired colonic motility
• Systemic disease
• Drugs- opioids, CCB, Iron, calcium, anticholenergics
Hypothyroidism
 Hyperparathyroidism
 Hypokalemia
 Parkinson’s, 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