Deranged (poor or increased) appetite occurs in infectious diseases, metabolic disorders, etc. Poor appetite or its complete absence (anorexia) is usually characteristic of gastric cancer. This symptom is often an early sign of cancer. Appetite often increases in peptic ulcer, especially in duodenal ulcer. Loss of appetite should be differentiated from cases when the patient abstains from food for fear of pain (citophobia). This condition often occurs in subjects with gastric ulcer, though their appetite is increased.
Perverted appetite that sometimes occurs in patients is characterized by the desire to eat inedible materials such as charcoal, chalk, kerosine, etc.
Appetite is perverted in pregnant women and in persons suffering from achlorhydria. Some patients with cancer of the stomach or some other organs often feel aversion to meat. The developmental mechanism of appetite is connected with excitation of the food centre (according to Pavlov). Excitation or inhibition of this centre depends on impulses arriving from the cerebral cortex, on the condition of the vegetative centres (excitation of the vomiting centre causes loss of appetite), and on reflex effects from the alimentary organs. The multitude of factors that act on the food centre accounts for the high variation in appetite.
Taste may be perverted due to the presence of unpleasant taste in the mouth and partial loss of taste in an individual. It can often be associated with some pathology in the mouth, e.g. caries or chronic tonsillitis. A coated tongue can be another cause of unpleasant taste in the mouth.
Regurgitation usually implies two phenomena: a sudden and sometimes loud uprise of wind from the stomach or esophagus (eructation), and the return of swallowed food into the mouth (sometimes together with air). Regurgitation depends on contraction of the esophageal muscles with the open cardia. Regurgitation may be due to air swallowing (aerophagy). It is heard at a distance and occurs in psychoneurosis. In the presence of motor dysfunction of the stomach, fermentation and putrefaction of food with increased formation of gas occur in the stomach (the phenomenon otherwise absent in norm). In abnormal fermentation in the stomach, the eructated air is either odourless or smells of bitter oil, which is due to the presence of butyric, lactic and other organic acids that are produced during fermentation in the stomach. In the presence of abnormal putrefaction, the belched air has the odour of rotten eggs (hydrogen sulphide). Bitter belching indicates intensive degradation of proteins. Belching is characteristic of stenosed pylorus with great distention of the stomach and significant congestion in it. Acid regurgitation is usually associated with hypersecretion of gastric juice and occurs mostly during pain attacks in ulcer. But it can also occur in normal or insufficient secretion of the stomach in the presence of insufficiency of the cardia (when the stomach contents are regurgitated into the esophagus). Bitter regurgitation occurs in cases with belching up of bile
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into the stomach from the duodenum, and also in hyperchlorhydria; bitterness depends on the bitter taste of peptone.
Pyrosis is otherwise known as heartburn, i.e. burning pain in the epigastric and retrosternal region. Heartburn arises in gastro-esophageal reflux, mostly in the presence of gastric hyperacidity in various diseases the alimentary tract (e.g. peptic ulcer or cholecystitis), hiatus hernia, and sometimes in pregnancy. Heartburn in healthy subjects can be due hypersensitivity to some foods.
Nausea is a reflectory act associated with irritation of the vagus nerve, indefinite feeling of sickness and sensation of compression in the epigastrium. Nausea is often attended by pallidness of the skin, general akness, giddiness, sweating, salivation, fall in the arterial pressure, cold the limbs, and sometimes semisyncopal state. Nausea often (but not necessarily) precedes vomiting. The mechanism of nausea is not known. Its frequent association with vomiting suggests that it might be the early sign of stimulation of the vomiting centre. The leading role in the development of nausea is given to the nervous system and also the tone of the stomach, the duodenum, and the small intestine. Nausea may develop without any connection with diseases of the stomach, e.g. in toxemia of pregnancy, renal failure, deranged cerebral circulation, and sometimes in healthy people in the presence of foul odour (or in remembrance of something unpleasant). Some diseases of the stomach are attended by nausea, e.g. acute and chronic gastritis or cancer of the stomach. Nausea associated with gastric pathology usually occurs after meals, especially after taking some pungent food. Nausea often develops in secretory insufficiency of the stomach.
Vomiting (emesis) occurs due to stimulation of the vomiting centre. This is a complicated reflex through the esophagus, larynx and the mouth (sometimes through the nose as well). Vomiting may be caused by ingestion of spoiled food, by seasickness, or irritation arising inside the body (diseases of the gastro-intestinal tract, liver, kidneys, etc.). In most cases vomiting is preceded by nausea and sometimes hypersalivation. Factors causing the vomiting reflex are quite varied. This can be explained by the numerous connections that exist between the vomiting centre (located in the medulla oblongata, in the inferior part of the floor of the 4-th ventricle) and all bodily systems. Depending on a particular causative factor, the following can be differentiated: (1) nervous (central) vomiting; (2) vomiting of visceral etiology (peripheral or reflex); (3) hematogenic and toxic vomiting.
Vomiting is an important symptom of many diseases of the stomach, it can be regarded as the symptom of a particular disease only in the sense of other signs characteristic of this disease. Vomiting of gastric etiology is caused by stimulation of receptors in the gastric mucosa by inflammatory processes (acute or chronic gastritis), in ingestion of strong acids or alkalis, or food acting on the gastric receptors by chemical (spoiled) or physical
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(overeating or excessively cold food) routes. Vomiting can be caused by difficult evacuation of the stomach due to spasms or stenosed pylorus. If patient complains of vomiting, the physician should inquire the time when the vomiting occurred, possible connections with meals, association with pain, the amount and character of the vomited material. Morning vomiting (on a fasting stomach) with expulsion of much mucus is characteristic of chronic gastritis, especially in alcoholics, Hyperacid vomiting in the morning indicates nocturnal hypersecretion of the stomach. Vomiting occurring 10-15 minutes after meals suggests ulcer or cancer of the cordial part of the stomach, or acute gastritis. If vomiting occurs 2-3 hours after meals (during intense digestion) it may indicate ulcer or cancer of the stomach body. In the presence of ulcer of the pylorus or duodenum, vomiting occurs 4-6 hours after meals. Expulsion of food taken a day or two before is characteristic of pyloric stenosis. Patients with peptic ulcer often vomit at the height of pain thus removing it, which is typical of the disease. The odour of the vomit is usually acid, but it can often be fetid (putrefactive processes in the stomach); the odour may be even fecal (in the presence of a fecal fistula between the stomach and the transverse colon).
The vomited material may have acid reaction (due to the presence of hydrochloric acid, in hyperchlorhydria), neutral (in achylia), or alkaline (in the presence of ammonia compounds, in pyloric stenosis, hypofunction of renal function, and also in regurgitation of the duodenal contents into the stomach). Vomitus may contain materials of great diagnostic importance, e.g. blood, mucus (in chronic gastritis), ample bile (narrowing of the duodenum, gastric achylia), and fecal matter. Vomiting may attend acute gastritis, exacerbation of chronic gastritis, gastric neurosis, peptic ulcer, spasm and organic stenosis of the pylorus, and cancer of the stomach.
Pain is the leading symptom in diseases of the stomach. Epigastric pain is not obligatory connected with diseases of the stomach. It should be remembered that the epigastrium is the "site of encounter" of all kinds of pain. Epigastric pain may be due to diseases of the liver, pancreas, and due to hernia of the linea alba. Epigastric pain may develop in diseases of other abdominal organs (sometimes of organs located outside the abdomen) by the viscero-visceral reflex (acute appendicitis, myocardial infarction, affection of the diaphragmatic pleura, etc). In order to locate correctly the source of pain, the physician should ask the patient (1) to show exactly the site of pain; (2) to characterize the pain which may be periodical or paroxysmal (at certain time of the day); permanent or seasonal (in spring or autumn); (3) to describe the connection (if any) between pain and meals, the quality of food and its consistency; (4) to indicate possible radiation of pain (into the back, shoulder blade, behind the sternum, left hypochondrium); (5) to describe conditions under which pain lessens (after vomiting, after taking food or baking soda, after applying hot-water bottle or taking spasmolytics); (6) to describe
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possible connections between pain and physical strain (weight lifting, traffic jolting, etc.), or strong emotions. Intensity and character of pain are also important diagnostically. The pain may be dull, stabbing, cutting, etc. Pain in hollow organs with smooth muscles (e.g. stomach) is provoked by spasms (spastic pain), distension of the organ (distensional pain), and by its motor dysfuncion.
Paroxysmal, periodical epigastric pain is due to the spasm of the pyloric muscles. It arises under the influence of strong impulses arriving from the vagus nerve centre in cerebral cortex dysfunction. The spasm of the pylorus is stimulated by the hyperacidity of gastric juice due to hyperstimulation of the vagus.
Depending on the time of paroxysmal pain (after meals), it may be early pain (occurring 30-40 min after meals), late pain (90-120 min after meals), nocturnal pain, and hunger pain (which is abated after taking food). If pain occurs after meals stimulating secretion of gastric juice (bitter, pungent, spicy or smoked foods), this indicates the leading role of hypersecretion in its etiology. The pain then localizes in the epigastrium, radiates to the back, and is rather intense; it is abated after vomiting and taking alkali or foods that decrease acidity of gastric juice, and also after taking antispastic preparations and applying hot-water bottle (which removes spasms).
A seasonal character of pain, i.e. development of periodic pain during spring and autumn, is characteristic of peptic ulcer, especially if the process is localized in the peripyloric region. Permanent boring pain is usually caused by stimulation of the nerve elements in the mucous and submucous layer of the stomach; the pain is usually intensified after meals and is characteristic of exacerbation of chronic gastritis or cancer of the stomach.
Perigastritis (chronic inflammation of the peritoneum overlying the stomach and its adhesion to the neighbouring organs) is manifested by pain developing immediately after taking much food (irrespective of its quality). The full stomach distends to stimulate nerve fibres in the adhesions. In the presence of perigastritis and adhesions between the stomach and the adjacent organs, pain may be caused by any physical strain and when the patient changes his posture.
Gastric hemorrhage is a very important symptom. It can be manifested by vomiting of blood (hematemesis) or by black tarry stools (melena). Gastric hemorrhage is usually manifested by the presence of blood in the vomitus. The colour of the vomitus depends on the time during which the blood is present in the stomach. If the blood was in the stomach for a long time, the blood reacts with hydrochloric acid of the gastric juice to form hematin hydrochloride. The vomitus looks like coffee grounds. If hemorrhage is profuse (damage to a large vessel) the vomitus contains much scarlet (unaltered) blood. Hematemesis occurs in peptic ulcer, cancer, and polyps, in
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erosive gastritis, rarely in sarcoma, tuberculosis and syphilis of the stomach, and in varicosity of the esophageal veins. Tarry stools are not an obligatory sign of gastric hemorrhage.
Anamnesis
When collecting anamnesis, the patient should be asked about his nutrition. It is important to establish if meals are regular because taking food at random is an important factor in the etiology of gastric diseases. Food quality is as important as its amount taken during one meal. Mastication of food matters as well. Conditions of rest and work, and possible occupational hazards should be established. Abuse of alcohol and smoking are important factors in the etiology of gastric diseases. It is very important to find out if the patient's condition has undergone some changes during recent time (e.g. loss of weight, anemia, blood vomiting, or tarry stools). Gastrointestinal diseases of the past, surgical intervention on the abdominal organs, long medication with preparations irritating the stomach mucosa (acetylsalicylic acid, sodium salycilate, steroid hormones, potassium chloride, etc.) are also very important.
Subjective examination in diseases of intestines
Complaints
The main complaints with intestinal diseases are pain, meteorism (inflation of the abdomen), motor dysfunction of the intestine (constipation and diarrhea), and intestinal hemorrhage.
Pain. If the patient complains of pain in the abdomen, the following should be established: location of pain, its radiation, intensity, character, duration, and means by which it is lessened. The general signs by which intestinal pain may be differentiated from gastric one are: (1) absence of regular dependence of pain on food taking; the only exception is inflammation in the transverse colon (transversitis): pain develops immediately after meals; the pathogenesis of this pain is connected with reflex peristaltic contractions of the transverse colon when food enters the stomach; (2) close association of pain with defecation: pain occurs before, during, and (rarely) after defecation; (3) pain relief after defecation or passage of gas.
Pain may be boring and spasmodic (intestinal colic). Colicky pain is characterized by short repeated attacks which arise and disappear quite of a sudden. Pain may very quickly change its location, the main site being round the navel. Sometimes pain may arise in other areas of the abdomen. Boring pain is sometimes permanent; it intensifies during cough, especially if the mesenterium or peritoneum is involved. Pain is characteristic of inflammatory diseases of the intestine. As inflammation extends onto the peritoneum, pain is attended by a pronounced muscular defence.
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