Page 144 - Medicine and Surgery

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140 Chapter 4: Gastrointestinal system

ulceration, whereas it may precipitate the pain of is- suggested by difficulty in initiating the swallow, or regur-
chaemia of the bowel. Vomiting or the passage of stool gitation into the nose, whereas oesophageal obstruction
or flatus may temporarily relieve pain. may manifest with food sticking retrosternally. Causes
are as follows:
Intraluminal blockage from the presence of a foreign

Nausea and vomiting body.
Intramuraldysphagiaresultingfrompharyngitis,ton-
Nausea is the sensation of impending vomiting, whilst
sillitis, candidiasis, oesophageal web, benign stric-
retching is the involuntary muscle contractions associ-
tures, carcinoma, achalasia or myasthenia gravis.
atedwithvomiting,withouttheexpulsionofgastriccon-
Extrinsic compression from thyroid enlargement,
tents. Vomiting may occur with or without nausea. The
pharyngeal pouch, mediastinal lymph node enlarge-
causes of nausea and vomiting are diverse, for example
ment, aortic aneurysm or paraesophageal hernia.
alcohol and drugs, motion sickness, pregnancy, many
Investigations that may be useful include videofluo-
gastrointestinal causes, neurological disorders and my-
roscopy, contrast swallow, upper gastrointestinal en-
ocardial infarction.
doscopy and chest imaging. See also under individual
Nausea and vomiting can be due to stimulation of the
conditions.
chemoreceptor trigger zones, located in the floor of the
fourth ventricle, or by vagal afferents from the gut. These
signals stimulate vomiting centres in the medulla. Diarrhoea
A history should elucidate the timing, precipitating
Diarrhoea is the abnormal passage of loose or liquid
and relieving factors of the nausea or vomiting and asso-
stools more than three times daily and/or a volume of
ciatedsymptomssuchasabdominalpain.Earlymorning
stool greater than 200 g/day. Patients may use the term
vomiting is characteristic of pregnancy, but also raised
diarrhoea in different ways. Diarrhoea lasting for more
intracranial pressure. Gastrointestinal obstruction may
than 4 weeks is generally considered chronic, likely
cause vomiting early or late in the condition depending
to be of noninfectious aetiology and warrants further
on the site of obstruction. Higher levels of obstruction
investigation.
tendtocausevomitingoflessdigestedfood,whichoccurs
Acute diarrhoea occurs with viral gastroenteritis, food
more rapidly after eating. Haematemesis is the vomiting
poisoning and traveller’s diarrhoea. Other symptoms
of blood, which may appear fresh or partially digested
such as pain, fever and vomiting may be present. In most
(coffee ground appearance).
cases specific treatments are unnecessary; however, ad-
Adrug history is important as many drugs can pre-
equate hydration (preferably using oral rehydration so-
cipitate nausea, especially drugs used in chemother-
lution) is essential.
apy. Peptic ulcer disease caused by nonsteroidal anti-
Chronic diarrhoea may be caused by organic or func-
inflammatory drugs (NSAIDs) may manifest as nausea
tional bowel disorders (e.g. irritable bowel syndrome).
and vomiting or even haematemesis, and a typical his-
Functional bowel disease tends to cause a prolonged his-
tory of epigastric pain may be elicited.
tory of intermittent diarrhoea, without weight loss. It
should be noted however that patients with inflamma-
tory bowel disease might present in this way. Organic
Dysphagia
disease is suggested by a history of diarrhoea of less than
Dysphagia or difficulty in swallowing usually indicates 3months duration, continuous or nocturnal diarrhoea,
organic disease. It differs from odynophagia (pain on or significant weight loss. Malabsorption often causes
swallowing). The history should establish duration, the steatorrhoea (stool that is frothy, foul smelling and floats
constant or intermittent nature, and whether it is worse because of a high fat content).
with solids or liquids. If solids are affected more than History taking in chronic diarrhoea should include
liquids, the cause is more likely to be obstruction, the following:
whereas liquids are affected more in neurological dis- Previous gastrointestinal surgery.
ease. Odynophagia that occurs with liquids suggests up- Anycoexistent pancreatic, endocrine or multisystem
peroesophageal ulceration. Pharyngeal problems are disease.