Exact location of the source of pain is very important. Pain in the right iliac region occurs in appendicitis, tuberculosis, cancer, or inflammation of the cecum (typhlitis). Acute pain in the left lower abdomen occurs in intestinal obstruction and inflammation of the sigmoid (sigmoiditis). Pain in the umbilical region occurs in inflammation of small intestine (enteritis) and inflammation or cancer of the colon. Pain in the perineal region, and especially during defecation (with the presence of blood in feces), is characteristic of the rectum diseases (proctitis, cancer). Pain in intestinal pathology may radiate into the chest; pain associated with affection of the spleen angle of the descending large intestine radiates into the left side of the chest (it is sometimes mistaken for pain attacks of angina pectoris); colics of appendicitic origin radiate into the right leg.
In acute affection of the left portions of the large intestine (dysentery), pain radiates into the sacral area. Thermal procedures, spasmolytics, passage of gas, and emptying of the bowels can relieve pain or remove it completely.
Intestinal pain is caused by obstruction of intestinal patency and upset motor function. Intestinal pain is mostly caused by spasms (spasmodic contraction of smooth muscles; hence spastic pain), or by distension of the intestine by gases. Both mechanisms often become involved.
Spastic pain can be due to various causes. Individual predisposition to spastic contractions in general (vegetoneurosis) may be as important as irritation originating in the intestine proper, e.g. in enteritis, colitis, intestinal tumour, poisoning with arsenic or lead, and also in diseases of the central nervous system (posterior spinal sclerosis).
Pain arising due to intestinal distension by gases, and associated with tension and irritation of the mesentery, differs from spastic pain (1) by the absence of periodicity; it is long-standing and gradually lessens in prolonged inflation; and (2) by exact localization. In intestinal obstruction (complete or partial) colicky pain is combined with almost permanent pain in the abdomen. It is characterized by exact and permanent location (the umbilical region and large intestine). The pain intensifies with intestinal peristalsis.
Appendicular colic first localizes round the navel and the epigastrium but in several hours (or even on the next day) it descends to the right iliac region where it intensifies gradually. Sometimes the pain arises straight in the right iliac region. Rectal colic, or tenesmus, is also known. It occurs in frequent and painful tenesmus to defecate and is associated with spasmodic contractions of the intestine and the sphincter ani. Only clots of mucus are sometimes expressed instead of actual defecation. Tenesmus occurs in dysentery and other inflammatory or ulcerous diseases, and in cancer of the rectum. Pain associated with defecation depends on many factors. Pain preceding defecation is associated with the disease of the descending colon or sigmoid colon. Pain during defecation is characteristic of hemorrhoids, anal fissures, and cancer.
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Meteorism. The patient feels flatulence, inflation, and boring distension of the abdomen. The causes of meteorism are (1) excessive gas formation in the intestine due to ingestion of vegetable cellular tissue and easily fermented food (peas, beans, cabbage, etc.); (2) intestinal motor dysfunction due to decreased tone of the intestinal wall or intestinal obstruction; (3) lowered absorbability of gases by the intestinal wall, the process of gas formation being normal; (4) aerophagia, i.e. excess swallowing of air, with its subsequent propulsion to the stomach and the intestine; (5) hysterical meteorism: the abdomen is rapidly inflated to the size of the abdomen of a pregnant woman at her last weeks; this nervous mechanism is very complicated.
When inquiring the patient, the physician should ask about the character of his nutrition and the site of abdomen inflation (the entire abdomen or only its limited part may be inflated). If inflation is local, it is necessary to ask the patient whether or not inflation occurs always at one and the same area. In intestinal obstruction, the patient feels rumbling sounds inside the abdomen, feels movement of liquid in the intestine, and intense peristaltic movements above the point of obstruction.
Diarrhea. Frequent and liquid stool is a common sign of intestinal pathology. Diarrhea occurs in acute and chronic intestinal infections (enteritis, enterocolitis, sigmoiditis, proctitis), in various exogenous intoxications (poisoning with arsenic or mercury), endogenous intoxications (uremia, diabetes, gout), in endocrine disorders (adrenal dysfunction, thyrotoxicosis), and in hypersensitivity to some foods (allergy).
The mechanism of diarrhea is very complicated. Different pathogenic factors may prevail in various pathological conditions. Accelerated movement of the liquefied food in the intestine due to peristalsis is among them. Almost undigested food can thus be evacuated. Another factor is disordered absorptive function of the intestine. Affection of the intestinal wall, disordered mechanisms regulating absorption, purgatives and upset water metabolism produce a marked change in the absorption process and are the cause of diarrhea.
The third cause of liquid stools is inflammation of the intestine. Large quantities of inflammatory secretion stimulating the intestinal receptors are released into the lumen of the intestine to intensify its peristalsis and to impair its absorptive function.
Paradoxical diarrhea occurs in prolonged constipation due to mechanical irritation of the intestinal wall by hard fecal masses.
Upset equilibrium between the fermentative and putrefactive flora of the intestine is another important factor in the etiology of diarrhea.
Diarrhea occurring in organic affections of the large intestine is mostly of the inflammatory character. It is not copious, nor does it produce strong negative effect on the patient's general condition (as compared with
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affections of the small intestine which is attended by profuse diarrhea associated with deranged motor and absorption function of the intestine). The pronounced disorder in digestion causes some metabolic disorders in the patient (impaired absorption of proteins, iron, vitamins, and electrolytes).
Obstipation (constipation). This is obstinate constipation during which feces are long retained in the intestine (for more than 48 hours). But the duration of constipation is only relative, because in many cases it is not the result of pathology but of the living conditions and nutrition. If vegetable food dominates in the diet, the subject may defecate two or three times a day. Stools become rarer if the diet is rich in meat. A radical change in nutrition can remove constipation. Limited mobility of the subject, hunger, and irregular defecations (during the day) may prolong pauses between defecation. The main factor determining defecation is the condition of intestinal motor function. Bowel contents are retained in the large intestine and the rectum during constipation
Organic and functional constipation is differentiated. Organic constipation is usually associated with mechanical obstruction, such as narrowing of the intestinal lumen due to a tumour, scar, adhesion, and also abnormalities in the intestine (megacolon, dolichosigmoid, megasigmoid, diverticulosis).
Functional constipation is subdivided into: (1) alimentary constipation; it occurs due to ingestion of easily assimilable foods, which leave small residue and normally stimulate peristalsis of the intestine by irritating its nervous receptors; (2) neurogenic constipation due to dysfunction of the intramural nervous apparatus or vagus nerve; these are the so-called dyskinetic constipation, caused by the reflex action on the intestinal motor function of another affected organ (cholecystitis, adnexitis, prostatitis, etc.), or by organic affections of the central nervous system (tumours of the brain, encephalitis, posterior spinal sclerosis); (3) constipation associated with inflammatory affections, mainly of the large intestine (dysentery); (4) toxic constipation occurring in exogenous poisoning with lead, morphine, or cocaine; (5) constipation of endocrine etiology, occurring in thyroid or pituitary hypofunction; (6) constipation caused by lack of physical exercise;
(7) constipation caused by flaccidity of the prelum.
Intestinal hemorrhage often occurs in ulcerous affections of the alimentary system. It develops in the presence of tumour, protozoal and helminthic invasions, acute infections (typhoid fever, bacillary dysentery), in thrombosis of mesenteric vessels, ulcerous non-specific colitis, etc.
Anamnesis
The patient should be inquired thoroughly about his nutrition from his early childhood till the onset of the disease (especially directly before the disease), about poisonings in the past history and hypersensitivity to some feeds. It is necessary to find out if the patient's meals are regular, if the food
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is varied, and if the patient smokes or drinks alcohol. Information on the past diseases of the intestine and also on pathology of other organs is sometimes decisive for establishing the cause of the present affection.
Some functional disorders of the intestine can be associated with occupation (lead or arsenic poisoning, constipation due to frequent suppression of tenesmus to defecate).
Objective examination of patients in diseases of digestive system
General survey of patients in diseases of digestive system
The general condition and state of consciousness of the patient are first assessed.
The general inspection of the patient with dysphagia may suggest an organic affection of the esophagus if the patient is extremely asthenic (cachexia). During general inspection of the patient with stomach diseases the physician may assess poor nutrition of the patient (cachexia) which is characteristic of stomach cancer and untreated benign pyloric stenosis. Patients with uncomplicated peptic ulcer look practically healthy. Severe prolonged affection of the absorptive function causes grave cachexia.
Pale skin is observed after gastric and intestinal hemorrhage, and in anemia. Edema is possible in loss of protein with simultaneous retention in the body of water and salt. Inspection of the skin reveals its dryness and pallidness; the mucosa is pale due to insufficient absorption of iron and anemization of the patient. Insufficient absorption of vitamins results in development of fissures of the lips, the skin becomes rough, and perleche develops.
Facies Нippocratica (first described by Hippocrates) is associated with collapse in grave diseases of the abdominal organs (diffuse peritonitis, intestinal obstructionб, perforated ulcer of the stomach or duodenum, rupture of the gall bladder). The face is characterized by sunken eyes, pinched nose, deadly livid and cyanotic skin, which is sometimes covered with large drops of cold sweat.
Survey of oral cavity
Next stage is inspection of the mouth. When inspecting the mouth, attention should be paid to its shape (symmetry of the angles, permanently open mouth), the colour of the lips, eruption on the lips (cold sores, herpes labialis), and the presence of fissures. The oral mucosa should also be inspected (for the presence of aphthae, pigmentation, Filatov-Koplik spots, thrush, contagious aphthae of the foot and mouth disease, hemorrhage). Marked changes in the gums can be observed in some diseases (such as pyorrhea, acute leukemia, diabetes mellitus, and scurvy) and poisoning (with lead or mercury). The teeth should be examined for the absence of defective shape, size, or position. The absence of many teeth is very important in the etiology of some
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alimentary diseases. Caries is the source of infection and can affect some other organs.
The absence of many teeth accounts for inadequate disintegration and mastication of food in the mouth, while the presence of carious teeth favours penetration of microbial flora into the stomach.
The tongue is not the "mirror of the stomach" as it was formerly believed. Nevertheless in some diseases its appearance is informative: clean and moist tongue is characteristic of uncomplicated peptic ulcer, while the tongue coated with a foul smelling white-grey material is characteristic of acute gastritis; a dry tongue indicates a severe abdominal pathology or acute pancreatitis; a tongue with atrophied papillae suggests cancer of the stomach, atrophic gastritis with pronounced gastric secretory hypofunction, or vitamin B deficiency. The glassy tongue is characteristic of gastric cancer, pellagra, sprue, and ariboflavinosis.
The tongue in intestinal diseases often becomes crimson (cardinal tongue) in vitamin PP deficiency (pellagra), its papillae are smoothed down. The gums may be loose and bleeding.
Disordered movement of the tongue may indicate nervous affections, grave infections and poisoning.
Survey of abdomen
Inspection of the abdomen should be done with the patient in vertical or lying position. Research of an abdomen in a vertical position begins with survey. Thus the doctor sits on a chair, and the patient faces the doctor, the person to him, completely having naked the abdomen.
For exact delimitation of localization of the signs revealed by objective inspection, abdomen conditionally part on some regions. Two horizontal lines (the first line bridges the tenth ribs, the second - the top edges of ileac bones) divide a front abdominal wall part on three departments, locating one under another: epi-, meso-and hypogastric regions. Two collateral vertical lines conducted on outside edges of rectus abdominis muscles divide epigastric region into two subcostal (hypogastric) regions (right and left) and (in more narrow sense) epigastric region posed in the middle; mesogastric - on two lateral flancs (flanks) and on umbilical region; hypogastric region - on two inguinal (ileac) regions locating on each side and suprapubic region.
At the beginning of survey the form of the abdomen is defined. In the healthy person the form of the abdomen substantially depends on his constitution.
The general outlines of the abdomen should be inspected. The abdomen can be of a normal shape with slightly protruding suprapubic region; it can be enlarged due to excess subcutaneous fat, and inflated in the presence of meteorism or ascites. Regularity of the abdomen shape should be assessed. An enlarged liver may protrude in the upper abdomen; an enlarged
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