GI History Flashcards
What should you always enquire about when doing a GI history?
- Pain
- Abdominal distension
- Nausea and vomiting
- Dysphagia (difficulty swallowing)
- Dyspepsia (indigestion / heartburn), hiatus hernia and peptic ulceration
- History of gallstones or previous pancreatitis
- Jaundice
- Altered bowel habit, diarrhoea, constipation or alternating diarrhoea and constipation
- Blood loss (haematemesis or rectal bleeding)
- Mucus or slime per rectum
- Appetite
- Weight change
- Continence
What is the socrates for a peptic ulcer?
Site: Epigastric
Onset: Acute or gradual. Remissions for weeks or months.
Character: Gnawing
Radiation: Into the back
Associated symptoms: Can lead to GI haemorrhage, peritonitis if perforates
Timing: Lasts 0.5 – 3 hours.
Exacerbating factors: Irregular meals (hunger), smoking, alcohol, aspirin and
NSAIDs
Alleviating factors: Food, antacids, vomiting
Severity: Mild to moderate
What is the socrates for acute cholycystitis?
Site: Epigastric or right hypochondriacal
Onset: Constant. Unpredictable frequency or periodicity.
Character: Stabbing, piercing
Radiation: Right scapula or tip of right shoulder
Associated symptoms: Vomiting, fever, rigors
Timing: 3 – 24 hours
Exacerbating factors: Sometimes food.
Alleviating factors: Pain relief by medication?
Severity: Severe
What is the socrates for acute pancreatitis?
Site: Epigastric Onset: Sudden or gradual Character: Piercing, stabbing, burning Radiation: Into the back. May develop generalised peritonitis with widespread pain. Associated symptoms: Nausea, vomiting, abdominal distension, shock Timing: Lasts more than 24 hours. Exacerbating factors: Eating Alleviating factors: Sitting upright Severity: Very severe
What questions should be asked about vomiting?
Vomiting can be triggered by a wide variety of local and systemic disorders e.g.
• Nervous system: motion sickness, labyrinthine disorders, migraine, meningitis, intracranial tumour
• Severe pain e.g. renal colic, myocardial infarction
• Systemic conditions e.g. pregnancy, renal failure, diabetic ketoacidosis, hyperparathyroidism
• Drugs by central action or local gastric irritation However, it is also a common symptom of gastrointestinal disorders e.g. gastric outlet obstruction, acute gastritis, acute cholecystitis, acute pancreatitis, hepatitis.
Ask:
• How frequent is the vomiting?
• What time of day does it occur?
• Taste, colour, smell and quantity?
• Is there any blood in the vomit (haematemesis)? Is it fresh blood altered blood (like coffee grounds)? If the patient is in the hospital, then try to inspect the vomit yourself whenever possible.
What questions should be asked about dysphagia?
Causes:
• Painful lesion in mouth or throat
• Neurological disorder e.g. pseudobulbar palsy
• Neuromuscular disorder e.g. myasthenia gravis
• Obstruction in the post-cricoid area e.g. pharyngeal pouch, tumour, stricture
• Obstruction at the lower end of the oesophagus e.g. tumour, achalasia of the cardia, stricture
Ask:
• Is it continuous or intermittent?
• How long does it last for?
• Where does the food stick?
• Is it solids, liquids or both?
• Does it occur between meals (may suggest globus hystericus, a psychogenic condition)?
• Do you suffer from acid reflux or dyspepsia?
• Nocturnal coughing or dyspnoea (2° to regurgitation and aspiration)?
• Enquire about the risk factors for oesophageal carcinoma: smoking, alcohol, obesity and diet lacking in fruit and vegetables
What questions should be asked about jaundice?
• Colour of urine and stools (differentiate haemolytic from obstructive jaundice)
• History of gallstones?
• Pain (pain of Ca pancreas is traditionally felt in the back and made worse on recumbency)?
• Fever and rigors?
• Itching?
• Social history
o Alcohol
o Drugs
o Foreign travel, including transfusions and tattooing abroad
o Unprotected sex
What questions should be asked about altered bowel habits?
Normal bowel habit varies widely between individuals. Changes in bowel habit are significant.
• How has the habit altered? Diarrhoea, constipation or both?
• Frequency of stools?
• Any associated abdominal discomfort or urgency?
• Incontinence?
• Appearance of stool? Consistency (formed or unformed)? Does it float in the pan? Associated blood, pus or mucus (slime)?
• Associated vomiting?
• Foreign travel?
• Medications, including over-the-counter remedies?
What questions should be asked about rectal bleeding?
Causes include
• Haemorrhoids (fresh red, clearly separate from the stool and may be seen only on the paper. Bleeding from haemorrhoids may splash into the pan after a motion and is generally painless)
• carcinoma of the colon or rectum (may be associated with mucus)
• inflammatory bowel disease (may be mixed with pus or mucus; stool may be unformed)
• diverticular disease
• anal fissures (fresh red, associated with severe anal pain during and after defaecation)
• melena (severe bleeding from the upper GI tract tends to be dark in colour (“altered”) and may contain clots – the patient may be in shock; smaller degrees of bleeding may result in dark stools)
What questions should be asked about abdominal distension?
Increasing girth is usually due to adiposity. Increasing girth in a patient who is otherwise becoming thinner suggests intra-abdominal disease e.g. subacute bowel obstruction, ascites, ovarian cyst, undiscovered pregnancy, chronic constipation.
What questions should be asked about loss of weight or loss of appetite?
- How much weight loss and over how long?
- Associated with loss of appetite or due to deliberate reduction in intake? Weight loss without reduction in food intake may be due to diabetes mellitus, hyperthyroidism or malabsorption syndrome. Loss of appetite may have a non-GI cause e.g. depression.
How can we complete the HPC of a gastro history?
In addition to your general survey, specifically include:
• Previous gastrointestinal problems, diagnoses and effectiveness of any treatments
• Previous gastrointestinal or abdominal surgery
• Gynaecological problems (pelvis communicates with abdomen)
• History of jaundice, anaemia, diabetes.
What drug history and allergy questions should be asked in a GI history?
Many drugs have gastrointestinal side effects, especially iron tablets, opiates, NSAIDs, antibiotics, anticoagulants and SSRI’s
What social history questions should be asked in a GI history?
Alcohol, smoking, occupation and diet. Recent foreign travel
What family history questions should be asked in a GI history?
There is a familial element to some carcinomas, Crohn’s disease and ulcerative colitis, malabsorption syndromes and Gilbert’s syndrome (inherited unconjugated hyperbilirubinaemia).
