Gastrointestinal history

Notes

Overview

The gastrointestinal (GI) history should focus on key system-specific symptoms related to the GI tract.

The gastrointestinal tract runs all the way from mouth to anus. Pathology can occur anywhere along the tract from oesophagus to the intestines to the bile ducts. Therefore, the GI history is a system-specific history that needs to focus on the different elements that can affect each part.

Any GI history should focus on the presenting symptom of the patient (e.g. diarrhoea or dysphagia) and then proceed to ask more broad questions related to other parts of the GI tract

History of presenting complaint

Isolate the primary symptom affecting the patient.

There are a plethora of GI symptoms and some can be specific to the upper GI tract, some specific to the lower GI tract and others to the hepatobiliary system. Explore these symptoms in more detail.

The key symptoms to determine in the GI history include:

  • Abdominal pain
  • Dysphagia: difficulty swallowing
  • Heartburn: reflux symptoms
  • Dyspepsia: indigestion (epigastric discomfort)
  • Nausea & vomiting
  • Change in bowel habit: constipation, diarrhoea
  • Bleeding: vomiting blood (haematemesis), melaena (Jet black stool), PR bleeding
  • Jaundice
  • Weight loss

Abdominal pain

The location and description of abdominal pain is critical to help localise the cause. Use your SOCRATES mnemonic and think about where and when the pain is occurring. For example:

  • Biliary colic - colicky right upper quadrant pain after meals
  • Diverticulitis - acute left iliac fossa pain +/- diarrhoea and fever
  • Peptic ulcer disease - chronic epigastric pain +/- reflux symptoms

Dysphagia

Determine the onset of dysphagia (e.g. sudden or gradual), whether it is related to the initiation of swallowing (i.e. oropharyngeal problems) or lower in the oesophagus. Also, think about whether it occurs with liquid (e.g. motility problem) or solids (e.g. structural problem).

Heartburn

Classically described as a burning retrosternal discomfort that may be associated with a bad taste at the back of the mouth (i.e. waterbrash). Heartburn is typically worse on lying down or bending forwards.

Change in bowel habit

There are several aspects to consider when asking about a change in bowel habit:

  • Onset: acute, subacute, chronic (> 6 weeks)
  • Consistency: loose, hard
  • Frequency: how many times a day or week
  • Additional features: blood or mucus present
  • Associated symptoms: any abdominal pain

Make sure you ask what their ‘normal’ bowel habit is like.

Bleeding

The two cardinal presentations of gastrointestinal disease are upper GI bleeding and lower GI bleeding that should always needs to be investigated. It can be a red flag sign for cancer.

  • Upper GI bleeding: haematemesis (vomiting bright red blood or ‘coffee ground’ material), melaena (jet black stool from digested blood)
  • Lower GI bleeding: passing bright red blood or altered blood. Blood may be seen on wiping with toilet paper, mixed with the stool, or just blood.

Jaundice

Jaundice usually locates the problem in the liver and hepatobiliary system. It will usually be obvious from the yellowing of the sclera and skin. Other features to consider:

  • Dark urine and pale stool: due to absence of breakdown products of bilirubin in the faeces and more being reabsorbed into the circulation
  • Previous episodes of jaundice?
  • Painless or painful: painless jaundice concerning for malignancy
  • Any known liver disease?

Past medical history

Enquire about any previous gastrointestinal or liver disease.

Ask about any pre-existing GI disease such as inflammatory bowel disease (IBD), peptic ulcer disease, or gallstones. Try to establish whether these are active problems (i.e. having ongoing treatment) or resolved problems (i.e. cholecystectomy for gallstones).

When discussing previous GI problems always establish:

  • Age of diagnosis (e.g. Crohn’s at 17 years old)
  • Treatment for condition (e.g. Azathioprine)
  • Any complications (e.g. hospital admission with acute flare 2/12 ago)
  • Previous investigations (e.g. colonoscopies, gastroscopies, or imaging)
  • Last follow-up & recommendations (e.g. known to an IBD team?)

Surgical history

It is essential to take a good surgical history in patients with GI problems.

Patients may have undergone abdominal surgery for a variety of gastrointestinal problems. Problems can also arise post-operatively due to adhesions or disease recurrence.

Make sure you determine the date of surgery, exact operation, and any complications.

For example:

  • Partial right hepatectomy, 2003. Colorectal cancer metastasis. No complications
  • Ileocolic resection. 2010. Crohn’s disease. Anastomotic leak
  • Cholecystectomy. 1995. Gallstone disease. No complications

Drug history

Make sure you ask about all medications including over the counter as NSAIDs can precipitate GI bleeding.

For gastrointestinal bleeding make sure you particularly enquire about NSAIDs, corticosteroids, and anticoagulants. These can all precipitate GI bleeding.

For acute diarrhoea ask about any recent antibiotics courses (e.g. risk of C. difficile).

For inflammatory bowel disease, ensure you enquire about previous, current, and future treatments that are planned. This may include newer biologic agents. Remember, patients may have had recurrent steroids courses and are at risk of steroid-related side-effects including adrenal insufficiency.

For liver disease, it is vital to ask about any illicit drug use (e.g. intravenous drug use) that increases the risk of viral hepatitis.

Family history

Many gastrointestinal diseases are hereditary (e.g. Lynch syndrome, familial adenomatous polypoisis).

Take a focused family history, particularly surrounding gastrointestinal cancer (e.g. gastric cancer, colorectal cancer), autoimmune disease (e.g. coeliac), and inflammatory bowel disease. Some patients with a family history may warrant surveillance to identify and treat cancer at an early stage (e.g. patients with Lynch syndrome need 2-yearly surveillance colonoscopy).

Determine family history within first-degree relatives (i.e. mother/father, brother/sister, children) and if relevant second-degree relatives. Also, think about the age of onset and maternal or paternal side. If relevant, has any family member had genetic testing?

Social history

Alcohol history is critical in patients with gastrointestinal disease.

Ensure you take a detailed alcohol and substance use history (including smoking). This may include CAGE screening questions or an AUDIT questionnaire to determine their risk of harm from alcohol and need for further investigation. For more information see Basic history note.

Alcohol use

This needs to be quantified based on a weekly average of alcohol intake. The national average for both men and women is now 14 units/week with several alcohol-free days and a max of 3-4 units in any one day.

Units of alcohol = alcohol percentage (%) per 1000 mls (e.g. 750 mL of 44% whiskey per day = 44 x 0.75 = 33 units / day)

Liver disease

In patients with new jaundice or deranged liver function tests (LFTs), there are a series of social history questions that are essential to determine the risk of liver disease, which include:

  • Any recent or previous foreign travel?
  • Were you unwell when you were abroad?
  • Did you need to receive any medical treatment including blood transfusions?
  • Any prior blood transfusions (particularly prior to 1991 for hepatitis C)?
  • Any tattoos? Where were these completed?
  • Any previous intravenous drug use or sharing needles?
  • Any previous vaccinations (e.g. hepatitis B vaccine)?

ICE

Always end by discussing the patient's ideas, concerns & expectations.

  1. Do you have an idea about what could be going on?
  2. Is there anything that is worrying/concerning you at the moment?
  3. Is there anything you were hoping for from this consultation?
  4. Do you have any further questions today?

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