The gastrointestinal system

John Plevris

Rowan Parks

Anatomy and physiology 94

The history 94

Common presenting symptoms 94

Past medical history 102

Drug history 102

Family history 102

Social history 102

The physical examination 103

General examination 103

Abdominal examination 104

Hernias 110

Rectal examination 111

Proctoscopy 113

Investigations 113

OSCE example 1: Abdominal pain and diarrhoea 116

OSCE example 2: Jaundice 117

Integrated examination sequence for the gastrointestinal system 117

94 • The gastrointestinal system

and 2000 kcal/day for females. Reduced energy intake arises

from dieting, loss of appetite, malabsorption or malnutrition.

Increased energy expenditure occurs in hyperthyroidism, fever

or the adoption of a more energetic lifestyle. A net calorie

deficit of 1000 kcal/day results in weight loss of approximately

RH

RF

LHE

UR

H

LF

RIF LIF

B

C

A

 1 Oesophagus

 2 Stomach

 3 Pyloric antrum

 4 Duodenum

 5 Duodenojejunal flexure

 6 Terminal ileum

 7 Caecum

 8 Appendix (in pelvic position)

 9 Ascending colon

10 Transverse colon

11 Descending colon

12 Sigmoid colon

3 Spleen

4 Pancreas

1 Liver

2 Gallbladder

1

2 4

3

4 3

5

1

2

9

7

8

6 12

11 10

Fig. 6.1 Surface anatomy. A Abdominal surface markings of

non-alimentary tract viscera. B Surface markings of the alimentary tract.

C Regions of the abdomen. E, epigastrium; H, hypogastrium or

suprapubic region; LF, left flank or lumbar region; LH, left hypochondrium;

LIF, left iliac fossa; RF, right flank or lumbar region; RH, right

hypochondrium; RIF, right iliac fossa; UR, umbilical region.

6.1 Surface markings of the main non-alimentary tract

abdominal organs

Structure Position

Liver Upper border: fifth right intercostal space on full

expiration

Lower border: at the costal margin in the mid-clavicular

line on full inspiration

Spleen Underlies left ribs 9–11, posterior to the mid-axillary line

Gallbladder At the intersection of the right lateral vertical plane and

the costal margin, i.e. tip of the ninth costal cartilage

Pancreas Neck of the pancreas lies at the level of L1; head lies

below and right; tail lies above and left

Kidneys Upper pole lies deep to the 12th rib posteriorly, 7 cm

from the midline; the right is 2–3 cm lower than the left

Anatomy and physiology

The gastrointestinal system comprises the alimentary tract,

the liver, the biliary system, the pancreas and the spleen.

The alimentary tract extends from the mouth to the anus and

includes the oesophagus, stomach, small intestine or small bowel

(comprising the duodenum, jejunum and ileum), colon (large

intestine or large bowel) and rectum (Figs 6.1–6.2 and Box 6.1).

The abdominal surface can be divided into nine regions by the

intersection of two horizontal and two vertical planes (Fig. 6.1C).

The history

Gastrointestinal symptoms are common and are often caused by

functional dyspepsia and irritable bowel syndrome. Symptoms

suggesting a serious alternative or coexistent diagnosis include

persistent vomiting, dysphagia, gastrointestinal bleeding, weight

loss, painless, watery, high-volume diarrhoea, nocturnal symptoms,

fever and anaemia. The risk of serious disease increases with age.

Always explore the patient’s ideas, concerns and expectations

about the symptoms (p. 5) to understand the clinical context.

Common presenting symptoms

Mouth symptoms

Bad breath (halitosis) due to gingival, dental or pharyngeal infection

and dry mouth (xerostomia) are common mouth symptoms.

Rarely, patients complain of altered taste sensation (dysgeusia)

or of a foul taste in the mouth (cacogeusia).

Anorexia and weight loss

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

In addition to enquiring about appetite, ask ‘Do you still enjoy

your food?’

Weight loss, in isolation, is rarely associated with serious

organic disease. Ask how much weight has been lost, over

what time. Loss of <3 kg in the previous 6 months is rarely

significant. Weight loss is usually the result of reduced energy

intake, not increased energy expenditure. It does not specifically

indicate gastrointestinal disease, although it is common in

many gastrointestinal disorders, including malignancy and liver

disease. Energy requirements average 2500 kcal/day for males

The history • 95

6

Dyspepsia

Dyspepsia is pain or discomfort centred in the upper abdomen.

In contrast, ‘indigestion’ is a term commonly used by patients

for ill-defined symptoms from the upper gastrointestinal tract.

Ask about:

• site of pain

• character of pain

• exacerbating and relieving factors, such as food and

antacid

• associated symptoms, such as nausea, belching, bloating

and premature satiety.

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).

Often there is no structural cause and the dyspepsia is

functional. There is considerable overlap, however, and it is

impossible to diagnose functional dyspepsia on history alone

without investigation. Dyspepsia that is worse with an empty