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Gastrointestinal symptoms

A primary care nurse's quick guide to…

Gastrointestinal symptoms

Key learning points:

1.    Gastrointestinal conditions are common - and commonly diagnosed and managed in primary care, either exclusively or via integration with secondary care

2.    History-taking in primary care - to determine location and severity of symptoms, and aggravating/alleviating factors - may be sufficient for some diagnoses

3.    Common primary care presentations

Presentations of gastrointestinal complaints are common and varied. Many GI disorders are common and require a multidisciplinary approach with close integration between primary and secondary care.1,2

GI disorders are a significant proportion of a general practice's responsibility, accounting for around a tenth of workload, and 80-90% of these patients are managed exclusively in primary care.2

History-taking and physical examination in primary care will in some cases be sufficient to make a diagnosis, or may be the starting point for referral and further testing.1

Here's your quick guide to GI diagnosis, with a particular focus on conditions that most commonly present or are most relevant to primary care.

Common complaints

Upper GI complaints include:

•   Chest pain.

•   Chronic and recurrent abdominal pain.

•   Dyspepsia.

•   Lump in the throat.

•   Halitosis.

•   Hiccups.

•   Nausea and vomiting.

•   Rumination.1

Lower GI complaints include:

•   Constipation.

•   Diarrhoea.

•   Gas and bloating.

•   Abdominal pain.

•   Rectal pain or bleeding.1

History-taking in gastroenterology

Taking a patient history aims to use an open style of questioning to determine the location and severity of symptoms, and aggravating and alleviating issues such as risk factors and genetic associations.1

Gynaecological factors should be considered in women.1

Abdominal pain

Abdominal pain is a frequent GI complaint and determining the location is a first step in diagnosis. The National Institute for Health and Care Excellence (NICE) pathway for GI conditions progresses by site of the condition:

•   Oesophagus.

•   Stomach.

•   Peritoneal cavity.

•   Small intestine, gall bladder and pancreas.

•   Large intestine.

•   Rectum and anus.1,3

The table below indicates how the location of abdominal pain may indicate possible diagnoses:1

Upper right quadrant

 

Indicates problems with:

•  liver

•  gall bladder

•  bile ducts

 

Such as:

•  cholecystitis

•  hepatitis

Epigastrium

 

Indicates problems with:

•  pancreas

•  stomach

•  small bowel

 

 

Lower right quadrant

 

Indicates inflammation of

•  appendix

•  terminal ileum

•  cecum

 

Suggesting:

•  appendicitis

•  ileitis

•  Crohn's disease

Lower abdomen, either left or right quadrant

 

Suggests:

•  colitis

•  ileitis

•  ovarianproblems

Lower left quadrant

 

Suggests:

•  diverticulitis

•  constipation

 

Other characteristics of the pain may also aid diagnosis, including:

•   Radiation (eg towards the shoulder may suggest cholecystitis).

•   Description (eg sharp or dull).

•   Onset (eg after surgery or injury).1

Eating habits

Questions should cover and/or establish:

•   Appetite.

•   Liquid intake.

•   Difficulty swallowing.

•   Nausea and/or vomiting (including presence of blood).1

Bowel movements

Questions should cover and/or establish:

•   Frequency and changes in frequency.

•   Description of stools.

•   Presence of blood.1

Gastroenteritis

Gastroenteritis presents as sudden-onset diarrhoea, with or without vomiting; it is usually caused by a virus, though some cases are bacterial or protozoan in origin. Around 10% of children under five will present to healthcare services with gastroenteritis each year.4

NICE advises that healthcare professionals should suspect gastroenteritis in under-fives if there is a sudden change in stool consistency to loose or watery, and/or sudden onset of vomiting. Further suspicion should be aroused by:

•   Recent contact with someone who has acute diarrhoea and/or vomiting.

•   Exposure to a known source of enteric infection.

•   Recent travel abroad.4

The NICE guideline on diagnosing and managing diarrhoea and vomiting caused by gastroenteritis in under-fives lists: additional symptoms that might indicate alternative diagnoses; and when to consider stool microbiological investigations, including if the diarrhoea has not improved by day seven.4

Irritable bowel syndrome

Irritable bowel syndrome (IBS) is a chronic condition characterised by abdominal pain or discomfort, which may be associated with defecation and/or accompanied by changes in bowel movements.5

Patients present to primary care with a wide range of symptoms.5

NICE recommends that healthcare professionals should consider assessment for IBS if the patient has had one or more of the following for at least six months (the ABC protocol):

•   Abdominal pain or discomfort.

•   Bloating.

•   Change in bowel habit.5

Its guideline on diagnosing and managing IBS in adults lists 'red flag' indicators that warrant referral to secondary care and other features of IBS that warrant consideration of the diagnosis.5

NICE's quality standard on IBS in adults states that patients with IBS symptoms should be offered tests for inflammatory markers first line to exclude inflammatory causes.6

GI bleeding

GI bleeding is bleeding that originates anywhere in the digestive tract and may present as blood in vomit or stools. It is a symptom of many GI disorders, with distinction made between the location, frequency and quantity of bleeding:7

•   Haematemesis describes vomiting of bright red blood and is indicative of upper gastrointestinal bleeding, often from a peptic ulcer, vascular lesion or varix.

•   Vomiting dark brown, coffee-ground-like material results from upper GIbleeding that has slowed or stopped.

•   Haematochezia describes the passage of gross blood from the rectum and usually indicates lower GI bleeding.

•   Melena is black, tarry stool and typically indicates upper GI bleeding.

•   Chronic occult bleeding can occur from anywhere in the GI tract and is detectable by chemical testing of a stool specimen.8

Bleeding in both the lower and upper GItract may indicate benign tumours or cancer.8

GI cancers

GI cancers are the commonest form of cancer in Europe. Colorectal cancer in particular is the third most common cancer in England and Wales, representing 14% of all cancers.2

NICE recommends upper GI endoscopy, with various degrees of urgency, to assess for oesophageal cancer in patients:

•   With dysphagia.

•   Aged 55 and over with other symptoms, particularly weight loss.

•   Haematemesis.9

The institute advises an urgent (within two weeks) ultrasound scan to assess for cancer in people with an upper abdominal mass consistent with either an enlarged gall bladder or an enlarged liver.9

Referral is recommended for suspected colorectal cancer for patients:

•     With a rectal or abdominal mass.

•     According to age and the presence of other symptoms listed in the NICE guideline on recognition and referral of suspected cancer.9

The same guideline recommends referral for suspected anal cancer for patients with an unexplained anal mass or unexplained anal ulceration.9

Further notes

The British Society of Gastroenterology (BSG) highlights the following conditions as of particular relevance to primary care practice.2

Gastro-oesophageal reflux disease and dyspepsia

BSG recommends that a majority of dyspepsia patients are managed in primary care. The condition accounts for up to 4% of GP consultations and, along with IBS, accounts for the majority of primary care GI workload.2

Liver disease

BSGrecommends that initial screening of liver function blood tests is carried out in primary care.2

Colorectal cancer

BSGrecommends that colorectal cancer screening is supported by primary care.2

References

1.     Moleski S. Evaluation of the GI patient. Merck Manual Professional Version. Merck. Revised November 2013 http://www.merckmanuals.com/professional/gastrointestinal-disorders/approach-to-the-gi-patient/evaluation-of-the-gi-patient(accessed June 20, 2016)

2.     British Society of Gastroenterology. Care of patients with gastrointestinal disorders in the United Kingdom - A strategy for the future. March 2006. http://www.bsg.org.uk/pdf_word_docs/strategy06_final.pdf

3.    Nice. Gastrointestinal conditions overview. http://pathways.nice.org.uk/pathways/gastrointestinal-conditions(accessed June 20, 2016)

4.    Nice. CG84. Diarrhoea and vomiting caused by gastroenteritis in under 5s: diagnosis and management. April 2009. https://www.nice.org.uk/guidance/cg84/chapter/Introduction

5.     Nice. CG61. Irritable bowel syndrome in adults: diagnosis and management. Updated February 2015. https://www.nice.org.uk/guidance/cg61

6.     Nice. QS114. Irritable bowel syndrome in adults. February 2016. https://www.nice.org.uk/guidance/qs114

7.     National Institute of Diabetes and Digestive and Kidney Diseases. Bleeding in the Digestive Tract. September 2014. http://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/bleeding-in-the-digestive-tract/Pages/facts.aspx(accessed June 20, 2016)

8.     Ansari P. Overview of GI Bleeding. Merck Manual Professional Version. Merck.Revised January 2016http://www.merckmanuals.com/professional/gastrointestinal-disorders/gi-bleeding/overview-of-gi-bleeding(accessed June 20, 2016)

9.     Nice. NG12. Suspected cancer: recognition and referral. June 2015. https://www.nice.org.uk/guidance/ng12