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
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:
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:
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).
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.
There are several aspects to consider when asking about a change in bowel habit:
Make sure you ask what their ‘normal’ bowel habit is like.
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.
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:
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:
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.
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.
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?
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.
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)
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:
Always end by discussing the patient's ideas, concerns & expectations.
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