Page 145 - Medicine and Surgery

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Chapter 4: Clinical 141

Family history of gastrointestinal neoplasia, inflam- hypokalaemia) and neurological diseases (spinal cord

matory bowel disease or coeliac disease. injury, multiple sclerosis). Constipation may also be the
Medication including previous antibiotics. presentation of bowel malignancy, which should be sus-

Foreign travel. pected in the older person, particularly if there is a

Screening tests should include full blood count, ESR, family history, history of rectal bleeding or weight loss.
CRP, urea and electrolytes, liver function tests, calcium, Left-sided colonic malignancies frequently present with
vitamin B 12 ,folate, iron studies, thyroid function tests atriad of alternating constipation and diarrhoea with
and coeliac serology. Infectious chronic diarrhoea is un- weight loss.
common in non-immunocompromised patients; how-
ever, stool cultures and microscopy should also be sent.
Associated symptoms
In young patients (under 45 years) with symptoms Constipation may cause colicky abdominal pains due
suggestive of functional bowel disease, a normal exam-
to peristalsis. This is common and not necessarily due
ination and negative screening tests, no further investi-
to aserious underlying disease.
gations are required. If atypical findings are present, a
Pain on passage of stool due to anorectal disease may
sigmoidoscopy should be performed. In older patients
lead to a deliberate suppression of the urge to defe-
colonoscopy with ileoscopy should be performed with cate and therefore the accumulation of large, dry, hard
biopsy and histological examination of any suspicious stools and constipation. This is a common cause of
areas. constipation in children.
Occasionally, constipation can present with watery

Rectal bleeding ‘overflow’ diarrhoea, due to increased gut secretions
passing around hard stool in the rectum. Alternating
It is important to determine if the bleeding is fresh bright
constipation and diarrhoea, often with bloating, pas-
redordark,andwhetheritisonthesurfaceofthestoolor
sage of mucus, and abdominal pains that are relieved
mixed in. Bright red blood on the toilet paper after wip-
by defecation, is commonly due to a functional bowel
ing is usually due to haemorrhoids. If the blood is mixed
disorder, e.g. irritable bowel disease. However, it is im-
in with the stool, or associated with various abdominal
portant to exclude malignancy if patients are over 45
symptoms, other pathology should be sought, in partic-
years or there are any suspicious features.
ular gastrointestinal malignancy. Black, tarry, offensive
smellingstoolisdigestedblood(melaena)andoriginates
fromthemoreproximalintestine.However,occasionally Weight loss
largeuppergastrointestinalbleeds(e.g.varices,pepticul-
Lossofappetite(anorexia)andweightlossareimportant
cers)cancausefreshrectalbleeding,althoughusuallythe
symptoms that may be due to an underlying gastroin-
patient will show signs of volume depletion such as hy-
testinal cause particularly cancer, but are also associated
potension, postural drop and tachycardia. Rectal blood
with other conditions including depression and any ma-
may occur with infection or inflammation of the bowel
lignancy. If there is an increased or unchanged appetite
(colitis). It is important to consider gastrointestinal ma-
together with weight loss, this suggests either malab-
lignancy in any case of rectal bleeding.
sorption or increased metabolic demand/state, e.g. due
to hyperthyroidism. The history should establish the du-
Constipation ration and severity of weight loss.
Constipation can be defined as a reduction in the fre-
quencyofbowelmovements.Anormalfrequencyiscon- GI presentations
sidered to be between three times a day and every 3 days,
but there is considerable individual variation. Hard, dif- The acute abdomen introduction
ficulttopassstoolsarealsoconsideredconstipation,even
if frequent. Patients with an acute abdomen are those with the fol-
Causes include drugs (e.g. opiates), endocrine or lowing clinical presentation:
metabolic causes (e.g. hypothyroidism, hypercalcaemia, Pain that may be local or more generalised.