symptoms and signs of lower gastrointestinal disease

SYMPTOMS AND SIGNS

Symptoms and signs oflower gastrointestinaldiseaseChristopher A Wadsworth

Ji-Peng Olivia Li

Andrew V Thillainayagam

Causes of acute and chronic diarrhoea

Acute Chronic

C Infection

Viral (adenovirus, Norwalk,

rotavirus)

Bacterial (Campylobacter,

E. coli, Shigella, C. difficile)

C Infections

Giardia

C Drugs (see Table 2)

C Malabsorption

Coeliac disease

AbstractSymptoms of lower gastrointestinal disease are common and are frequent

triggers for consultation in primary and secondary care. Diarrhoea,

abdominal pain and constipation can represent a wide range of different

underlying pathologies, from chronic, benign, functional conditions to

acutely life-threatening emergencies. Lower GI bleeding frequently repre-

sents serious pathology and requires rational investigation based on

a systematic assessment of the history and clinical presentation. Extra-

intestinal manifestations of lower GI disease can often give a clue to

the underlying diagnosis. In this contribution, we review the aetiology,

clinical features, investigations and management for a range of lower

gastrointestinal symptoms. These include diarrhoea, constipation, lower

GI bleeding, bloating and abdominal pain.

Keywords abdominal pain; bloating; constipation; diarrhoea; lower GI

bleeding

Diarrhoea
C Drugs
C

Pancreatic insufficiency
Definition
Ischaemic colitis

C Inflammatory bowel disease

Short bowel syndrome

Bile salt malabsorption

Bacterial overgrowth

C Inflammatory bowel disease

Ulcerative colitis

Crohn’s disease

C Collagenous colitis

C Eosinophilic colitis

C Metabolic disease

Diabetes mellitus

The strict definition of diarrhoea is stool volume of more than

200 ml per day, or a stool frequency of more than three times per

day. This is widely accepted as the technical definition of diar-

rhoea and is frequently used in clinical studies. However, it may

be of less utility in the clinical assessment of an individual

patient. A simpler and less arbitrary definition is ‘a decrease in

consistency or increase of liquidity of stool’; this is widely

accepted in clinical practice and accords well with what patients

understand by ‘diarrhoea’. Diarrhoea is defined as acute when it

has been present for less than four weeks, chronic if longer.

Christopher A Wadsworth MBBS MRCP is a Specialist Registrar in

Gastroenterology at St Mary’s Hospital, Paddington and Clinical

Research Fellow, Imperial College, London, UK. Competing interests:

none declared.

Ji-Peng Olivia Li MA MBBS AICSM is a foundation year trainee in the North

West Thames Foundation School, London, UK. Competing interests:

none declared.

Andrew V Thillainayagam MD FRCP is a Consultant Physician at Ham-

mersmith Hospital and Honorary Senior Lecturer in Medicine at Imperial

College, London, UK. Competing interests: none declared.

MEDICINE 39:2 72

Prevalence of chronic diarrhoea in the developed world is

approximately 5% in symptom questionnaire population studies.

Aetiology and classification

There are four mechanisms:

� reduced absorption of osmotically active substances

� abnormal secretion

� inflammatory damage to the mucosa

� reduced transit time.

Most diarrhoeal conditions result from a combination of these

processes.

It is useful to classify diarrhoea as acute or chronic as this can

narrow the differential diagnosis and allow rational investigation

(Table 1).

Important clinical features

A detailed history is essential. Onset, duration, frequency, and

volume of stool should be estimated. Bloody diarrhoea with pus

or mucus suggests a predominantly inflammatory process. A

bulky, greasy, foul-smelling stool is highly suggestive of stea-

torrhoea. Urgency to defecate is a feature of proctitis, particularly

when associated with blood or pus per rectum. Nocturnal

Hyperthyroidism

C Neoplastic

Bowel cancer

Pancreatic cancer

Carcinoid, VIPoma,

medullary cancer

of the thyroid

C Functional

Irritable bowel syndrome

Faecal impaction

Iatrogenic anal sphincter

damage

Purgative abuse

Table 1

� 2010 Published by Elsevier Ltd.

http://dx.doi.org/10.1016/j.mpmed.2010.11.006

Common drugs that can cause diarrhoea

C Antibiotics

C Digoxin

C Serotonin re-uptake inhibitors (SSRIs)

C Lithium

C Metformin

C Non-steroidal anti-inflammatory drugs (NSAIDs)

C Proton pump inhibitors (PPIs)

C Ranitidine

C Statins

C 5-Aminosalicylates (5-ASAs)

Table 2

SYMPTOMS AND SIGNS

symptoms, continuous symptoms, a duration of over 3 months

and significant weight loss all point to an organic rather than

functional process. Associated symptoms, such as abdominal

pain, bloating, nausea and vomiting, should be sought.

A history of HIV disease or other immunosuppressant states

should trigger investigation for an infective cause, including

atypical organisms. Radiotherapy to the abdomen or pelvis, or

previous bowel surgery can lead to bacterial overgrowth. A

history of biliary or small bowel surgery raises the possibility of

bile salt malabsorption. Diabetic patients are prone to dysmotility

or bacterial overgrowth. Recent antibiotic use predisposes to

C. difficile infection. The drug history may be relevant as many

commonly prescribed medications can cause diarrhoea (Table 2),

as can recreational drugs, such as alcohol and cocaine. A history

of dietary indiscretion or foreign travel may point towards an

infective cause. Anal intercourse can lead to HSV or gonococcal

proctitis. Long-standing alcohol excess may indicate an under-

lying pancreatic abnormality.

A family history of inflammatory bowel disease (IBD) or

gastrointestinal malignancy should be sought. General exami-

nation may reveal jaundice, hepatomegaly, cachexia or extra-

luminal signs of GI disease that may give clues to the cause of the

diarrhoea. A palpable mass may result from malignancy or

Crohn’s disease. Fluid status should be checked carefully and

dehydration, sepsis, peritonism or shock should be recognized

and treated promptly.

Investigations

Uncomplicated acute diarrhoea requires no investigation. Severe

or prolonged symptoms should trigger stool microscopy and

culture. Full blood count, ESR, CRP and albumin should be

measured. Flexible sigmoidoscopy and biopsy and plain abdom-

inal radiography are necessary in those patients with bloody

diarrhoea, systemic disturbance or significant abdominal tender-

ness, and in those whose symptoms do not settle promptly.

Investigation of chronic diarrhoea is guided by the history and

likely underlying diagnosis. Further blood tests include anti-

endomysial or anti-tissue transglutaminase antibodies (for

coeliac disease), amoebic serology, thyroid function tests (TFTs),

iron studies, and serum folate and vitamin B12.

Colonoscopy to exclude colonic neoplasia is almost manda-

tory in patients over the age of 45 with persistent diarrhoea.

Younger patients with associated red-flag features, such as

weight loss, PR bleeding or anaemia, also warrant full

MEDICINE 39:2 73

colonoscopy to exclude colonic neoplasm or inflammatory bowel

disease. In very elderly patients, or those with extensive co-

morbidity, CT pneumocolonography is a less invasive test that

can reliably exclude colonic neoplasm. However, it does not offer

the same sensitivity for mucosal disease or very small lesions. In

young patients with typical features of functional bowel disease,

normal physical examination and normal blood screen no further

investigation is necessary. Small bowel imaging, with MR

enteroclysis or barium follow-through should be undertaken in

patients with suspected small bowel disease such as Crohn’s

disease.

Repeat stool microscopy and culture should be sent. A three-

day stool collection can be performed and a volume of �200 ml/

day (roughly equivalent to a mass of 200 g) is highly suggestive

of a functional disorder. A laxative screen can be sent if factitious

diarrhoea is suspected. A faecal elastase can be sent to assess

pancreatic exocrine function.

In patients with symptoms of malabsorption, CT imaging of

the pancreas and hydrogen breath testing may be undertaken

to exclude pancreatic pathology and lactose intolerance/

bacterial overgrowth respectively. A Se-HCAT scan can

exclude bile salt malabsorption, an under-diagnosed cause of

chronic diarrhoea. Enteropathies such as coeliac disease can

be confirmed by endoscopy with duodenal biopsy. A trial of

empirical treatment, such as pancreatic supplements or a bile

salt sequestrant, may be necessary when no obvious cause is

demonstrated.

Constipation

This is a common complaint with an estimated prevalence of

2e28%. Most cases can be managed successfully with reassur-

ance and dietary advice.

Definition

A number of symptoms can be used to define constipation, and

patients will often complain of a combination of the following:

� infrequent stools (<3 per week)

� difficult passage of hard stool

� need for digital examination of rectum and/or vagina to aid

evacuation

� sense of incomplete defecation (tenesmus)

� excessive straining or time spent on the toilet.

Absolute constipation is the inability to pass stool or flatus per

rectum and this is suggestive of bowel obstruction, particularly if

it is accompanied by concurrent vomiting. This is a medical

emergency.

It is important to elicit any alarm symptoms present, partic-

ularly weight loss, bleeding, distension and new-onset con-

stipation in the elderly.


It is useful to consider the contributory mechanisms to con-

stipation, particularly:

� increased absorption/reduced consumption of osmotically

active substances

� mechanical obstruction of the bowel lumen

� secondary causes of prolonged transit times.

Constipation may also be a behavioural response secondary to

painful defecation or maladaptive learning from childhood.



Causes of constipation

Simple/functional Organic/systemic disease

C Poor diet

C Elderly

C Lack of exercise

C Idiopathic slow-transit

constipation

C Irritable bowel syndrome

Drugs

C Opiates

C Antidepressants

C Aluminium antacids

C Iron

C Anticholinergics

Metabolic

C Hypothyroidism

C Hypercalcaemia

Pregnancy

Obstructive

C Neoplasm

C Crohn’s

Neurogenic

C Diabetes mellitus

C Autonomic neuropathy

C Hirschprung’s disease

C Spinal cord lesions

C Intestinal pseudo-obstruction

C Parkinson’s disease

Anorectal

C Mucosal prolapse

C Rectocoele

C Fissure

C Dyssynergic defaecation

Table 3

SYMPTOMS AND SIGNS

It is important to distinguish functional constipation from

constipation that has an organic cause. The former is common in

patients who present with a long history of constipation without

any alarm symptoms. These patients usually have normal

colonic transit, require no investigation and typically respond to

dietary modification and osmotic laxatives.

Slow-transit constipation may have an organic cause, such

as an adverse effect of drugs (Table 3), or neurogenic disorders

like diabetes mellitus, autonomic neuropathy or Hirschsprung’s

disease. Idiopathic slow-transit constipation is more common

in young women. Whatever the aetiology, slow transit usually

means that long-term use of an osmotic laxative will be

required.

Constipation may also be a dominant feature of irritable

bowel syndrome, a functional disorder of chronic abdominal

pain and deranged bowel habit. Long-term avoidance of pain

associated with passing hard stools, the presence of anal fissures

or haemorrhoids, along with structural abnormalities, such as

a rectocoele, are other causes of constipation.

Causes of constipation, although often multifactorial, are

shown in Table 3.


A detailed history is required to exclude organic causes, decide

which patients require further investigation and whether the

patient is indeed constipated. Attention should be paid to

the medical history, including obstetric history in women,

current medications and dietary history. The psychosocial

history can be relevant, as a history of psychiatric illness or

sexual abuse is a risk factor for non-organic constipation.

Features suggestive of a functional cause include a long (often

lifelong) history, other symptoms compatible with irritable

MEDICINE 39:2 74

bowel syndrome (IBS) and presentation in a younger patient

(<50 years of age). A recent sudden change in bowel habit in

older patients (>50 years of age) or the presence of alarm

symptoms, such as bleeding or weight loss, warrants further

investigation, as does the acute onset of absolute constipation.

Problems with initiating defaecation, prolonged straining or

digital evacuation may indicate a severe structural or functional

evacuatory disorder.

A thorough examination of the abdominal system is required

in all patients, and should always include careful inspection of

the perineum for scars, fissures, fistulae and external haemor-

rhoids. Digital rectal examination is required to assess the anal

reflex, sphincter tone, and any evidence of structural abnor-

mality or faecal impaction.

Investigations

Basic tests: a detailed history, examination and simple

screening blood tests (full blood count, electrolytes, calcium,

glucose, and thyroid function) will help exclude most

secondary causes and identify those who require further

investigation. Colonoscopy is reserved for patients in whom

colorectal cancer or inflammatory disease needs to be excluded

(alarm symptoms, new onset after 50 years of age, significant

family history of colorectal neoplasia or IBD). In acute-onset

constipation with abdominal pain and vomiting, a chest and

abdominal radiograph is always necessary to exclude obstruc-

tion and/or perforation.

Specialist tests: various physiological tests can be performed in

those patients who do not respond to a high-fibre diet and are

refractory to laxatives. Colonic transit studies (normal transit

time <72 h) will help identify slow-transit constipation or a -

defecatory disorder. Balloon expulsion, anorectal manometry

and defaecography are all useful in order to diagnose disordered

evacuation.

Management

Education regarding diet, exercise and what is a ‘normal’ bowel

habit is essential. Secondary causes, anorectal abnormalities and

systemic disease should be identified and treated appropriately.

In those with severe, intractable constipation, an initial bowel

purge using any potent osmotic laxative regimen followed by

regular high doses of a gentler osmotic laxative and stimulant

laxative may be necessary.

Surgery (subtotal colectomy and ileorectal anastomosis)

remains controversial and should be considered only in those

who have severe refractory slow-transit constipation with no

evacuation disorder. It should be considered only after all

medical therapies have failed and when more than one expert

opinion has been sought.

Lower gastrointestinal bleeding

Definition and causes

Haematochezia is the passage of fresh or partially altered blood

per rectum. Most bleeding will be either colorectal or anal in

origin, small bowel lesions are rarely the cause. Haematochezia,

albeit rarely, can be the consequence of massive upper GI

bleeding, where rapid transit results in minimal digestion. An



Causes of lower GI bleeding

Common Rare

Perianal disease

C Haemorrhoids

C Anal fissure

Diverticular disease

Colorectal polyps

Colorectal carcinoma

Inflammatory bowel disease

Infectious colitis

Ischaemic colitis

Arteriovenous malformation

Radiation proctitis

Anorectal varices

Meckel’s diverticulum

Arterio-enteral fistula

Table 4

SYMPTOMS AND SIGNS

upper GI source should be excluded in all shocked, anaemic

patients with acute onset of haematochezia.

Melaena is the passage of substantially digested blood that

appears black. Melaena is a consequence of upper or midgut

bleeding and is not considered further in this article. Acute lower

GI bleeding is common, although massive bleeds are rare and

usually secondary to diverticular disease or ischaemic colitis.

Chronic PR blood loss often relates to perianal disease, colonic

inflammation or neoplastic disease. Causes are listed in Table 4.


Causes of abdominal pain

Acute Chronic

Small or large bowel obstruction Chronic peptic ulcer disease

Perforated peptic ulcer disease Gastritis

Ectopic pregnancy Irritable bowel syndrome

Ovarian torsion/cyst rupture Intra-abdominal malignancy

Mesenteric infarction Pelvic inflammatory disease

Volvulus Constipation

Diverticulitis Hypercalcaemia

Appendicitis Porphyria

Pancreatitis Inflammatory bowel disease

Gastroenteritis

The patient’s history will give clues as to the cause and site of the

bleeding. Questions should be focused on:

� the colour of the blood

� exactly when and where the blood is seen

� duration

� any change in bowel habit or diarrhoea

� presence of abdominal pain

� any associated symptoms

� travel history

� previous episodes

� risk factors for bleeding.

Bright red blood seen either separate from the stool or after

wiping is likely to be secondary to anorectal disease. Bloody

diarrhoea with or without mucus suggests an inflammatory,

neoplastic or infective aetiology. Colorectal carcinoma and

polyps may present with minor, intermittent rectal bleeding.

Occult lower GI bleeding may be detected by testing stool

samples for faecal occult blood in screening programmes for

colorectal neoplasia.

The age of the patient will influence the likely differential

diagnosis; malignancy, ischaemic colitis, diverticular disease and

arteriovenous malformations are much more common in older

patients.

Examination may reveal the presence of a mass or identify

anorectal disease. A digital rectal examination should always be

performed, although benign anorectal lesions are common and

further colonic investigation is often still required.
Cholecystitis
Nephrolithiasis
Investigations
Ruptured or dissecting aortic aneurysm

Inflammatory bowel disease

Table 5

Basic tests:blood tests should include full blood count, electrolytes,

clotting and iron studies. Colonoscopy to assess the large bowel,

with or without gastroscopy if an upper gastrointestinal source is

thought possible, will identify the cause in the majority of cases.

MEDICINE 39:2 75

Specialist tests: those cases where the source of bleeding cannot

be identified readily often require referral to a specialist centre,

where upper and lower GI endoscopy is usually repeated.

Assessment of the small bowel can be performed with an

enteroscopy, barium follow-through or MR enteroclysis. Video

capsule endoscopy is now widely available and is a more

sensitive technique to identify small bowel mucosal lesions. A

Tc99m-labelled red cell scan can localize the source of ongoing

bleeding in the acute situation but is rarely used. Mesenteric

angiography can reliably identify the site of brisk bleeding (>1

U/4 h) and offers the opportunity for embolic therapy. In

younger patients, a Meckel’s scan should be performed early on.

Management

Themajority of acute lower GI bleeding resolves spontaneously, the

patient should be resuscitated as necessary and most can be

managed conservatively with blood products, if required, without

the need for surgery. Once the bleeding has resolved, further

investigation to identify the site of bleeding, usually with colono-

scopy, can be undertaken. Where bleeding is ongoing and not

resolving, urgent gastroscopy and colonoscopy are required, fol-

lowed if necessary by mesenteric angiography, during which selec-

tive embolization can be performed. Surgical resection is indicated

for severe, persistent bleeding where the site has been localized.

Abdominal pain

Abdominal pain, both chronic and acute, is a common presenting

complaint in primary and secondary care. The differential diag-

nosis is broad and the clinician must ensure that those with

serious underlying pathology, such as visceral perforation,

receive prompt treatment whilst those with more benign condi-

tions, such as IBS, are not submitted to excessive investigation.

Definition

Pain is a sensory perception to noxious stimuli, often with an

associated emotional response. In the abdomen, pain may be

categorized into visceral, parietal or referred pain.

The causes of abdominal pain are detailed in Table 5.



SYMPTOMS AND SIGNS


The character of abdominal pain is important in narrowing the

range of differential diagnoses. Visceral pain is poorly localized,

tends towards the midline and is often described as dull,

cramping or burning. Stretching of hollow viscera is the key

mechanical stimulus in visceral nociception. Pain is roughly

localized to the epigastrium, peri-umbilical or suprapubic regions

if the origin is in the embryological foregut, midgut or hindgut

respectively. This pain may be colicky, worsening with each

episode of peristalsis of the hollow viscus, as is seen in renal colic

with ureteric stones or early intestinal obstruction. Associated

autonomic phenomena, such as sweating, pallor, vomiting and

nausea, are common.

Somatoparietal pain originates from the peritoneum and is

better localized and sharper in character than visceral pain. This

pain tends to be more constant and is often associated with

inflammation. For instance, in advanced appendicitis, pain is

localized to the right iliac fossa once local inflammation begins to

involve the adjacent peritoneum.

Referred pain is pain perceived to be originating from a site

distant from the affected organ. This occurs because visceral

afferent nerve fibres enter the spinal cord adjacent to somatic

inputs, activating the same spinothalamic pathways. The visceral

afferent signal is wrongly perceived as a somatic one, localizing

the pain to the cutaneous dermatome at the same level as the

visceral input. In early cholecystitis, there may be referred pain

to the scapula, localization to the right upper quadrant only

appearing later when the gallbladder inflammation involves the

peritoneum.


The location, timing, periodicity, onset, character and intensity of

the pain should be explored, as well as aggravating or relieving

factors. The location of pain, and its radiation may clearly narrow

the range of differential diagnoses. However, the combination of

visceral, somatoparietal and referred pain leads to a misleading

presentation e for instance, the vague central abdominal pain of

early appendicitis, which evolves into a more severe, localized

pain once the peritoneum becomes involved.

In general, an acute presentation with sudden and progressive

onset of pain is associated with catastrophic conditions, such as

a perforated viscus, dissecting aorta, or infarcted gut. A slower

onset over weeks or months points to a more benign process. The

relapsingeremitting character of renal colic may give a clear

clue. Relief of pain by defecation may point to a functional bowel

disorder, such as IBS. Patients with peritonitis tend to lie very

still as movement exacerbates the pain. Those with renal colic

tend to move around a lot, trying to find a comfortable position.

Exacerbation of the pain by a high-fat meal might point to

a biliary or pancreatic source to the pain, although oesophageal

pain can also be made worse by fat ingestion.

Extra-abdominal causes of pain should also be considered.

Epigastric pain may be the presenting complaint of acute

myocardial infarction. Neuropathic pain may precede the

dermatomal vesicular rash of herpes zoster reactivation.

Physical examination should include assessment of any septic

or hypovolaemic shock. Icterus or obvious anaemia should be

noted. Systematic palpation and percussion of the abdomen

should be undertaken, noting any tenderness, guarding, rebound

MEDICINE 39:2 76

tenderness, free fluid, masses or organomegaly. Bowel sounds

and any bruits should be auscultated. Examination of the hernial

orifices and digital per rectum examination are mandatory.

Investigation

Investigation of a patient with abdominal pain is determined by

the pattern of presentation, but should usually include full blood

count, urea and electrolytes, amylase, liver function tests, bone

profile and inflammatory markers. In acute severe abdominal

pain, plasma lactate and arterial blood gas analysis are manda-

tory. Urine analysis should be performed. A pregnancy test

should be performed in all potentially fertile females. An erect

chest radiograph and plain abdominal radiograph are usually

required to identify obstruction or perforation. CT of the

abdomen and pelvis is highly sensitive for the assessment of the

acute abdomen.

Chronic abdominal pain without identifiable organic cause

requires careful history-taking and consideration of cultural and

social influences on the perception of pain. Irritable bowel

syndrome should be considered in the absence of a clear organic

cause, particularly if associated with constipation, diarrhoea or

bloating.

Subsequent investigation is normally targeted at the likely

underlying diagnosis.

Management

Initial management of patients with acute abdominal pain

includes fluid resuscitation, treatment of any sepsis with antibi-

otics, and analgesia. Again, subsequent management is directed

towards the most likely underlying condition. Prompt laparos-

copy or laparotomy may be indicated, particularly if a perforated

viscus or vessel is suspected. The management of chronic

abdominal pain can prove difficult. Irritable bowel syndrome

may respond to a variety of agents, including peppermint oil,

laxatives, antispasmodics or low-dose antidepressants (SSRI or

tricyclic). In refractory cases of idiopathic abdominal pain

referral to a chronic pain service may be required.

Bloating

Definition

Bloating is a poorly defined term that refers to a variety of

subjective sensations and an objective increase in abdominal girth.

Patients may use it to describe a sensation of abdominal fullness,

a feeling of abdominal tension or the sensation of excess gas. In

one review, up to 24% of those surveyed described themselves as

bloated but without any visible abdominal distension.

Classification

Bloating is highly prevalent and affects 10e30% of the pop-

ulation. However, it is not recognized as a disorder in its own

right, but is regarded as a common secondary symptom in

a variety of functional disorders, including non-ulcer dyspepsia

and IBS. In the former, it is most commonly located in the upper

abdomen, whereas in the latter it is more likely to be localized to

the lower abdomen and associated with constipation. Bloating is

more common in women than men and varies in severity from

mild to severe discomfort. Three-quarters of patients feel bloat-

ing worsens after eating, particularly large, fatty or high-fibre



SYMPTOMS AND SIGNS

meals. There is often a circadian rhythm to bloating as it

develops during the day and lessens at night. Stress is frequently

reported as exacerbating bloating. In up to 40% of women,

bloating worsens premenstrually.

Aetiology

The aetiology of bloating is complex and incompletely understood.

In some disorders there is clearly excess gas production, such as in

bacterial overgrowth where abnormal fermentation of foodstuffs

takes place within the small bowel. However, the evidence for

excess gas production is weaker in functional syndromes, which

account for the majority of cases in which bloating occurs.

Visceral hypersensitivity is likely to be important, with normal

volumes of gaseous distension causing the sensation of bloating in

susceptible individuals. Visceral hyperalgesia is certainly well

described in patients with both functional dyspepsia and IBS.

Impaired gas handlingwithin the GI tract is also likely to play a key

role. Studies have shown impaired intestinal propulsion, with

uncoordinated intestinal motility in individuals who experience

bloating. The small bowel is the region of the GI tract which has

most consistently been shown to be affected.

Investigation and treatment

The majority of cases in which bloating occurs are functional;

however, organic disease must be considered. Coeliac disease,

bacterial overgrowth and other causes of malabsorption should

be excluded. Treatment of bloating is usually directed at the

associated condition rather than the symptom itself.

Clinical conditions associated with bloating

Constipation: in many patients, the symptoms of bloating relate

directly to bowel habit. Bloating frequently develops prior to, and

is relieved by, defecation. Bloating is described by up to 80% of

subjects with simple constipation and is often effectively treated by

laxatives.

Diarrhoea: bloating is associated less frequently with diarrhoea

than constipation. Patients with bloating and diarrhoea are most

likely to have diarrhoea-predominant IBS. However, they may

have organic disease and should be evaluated for causes of

malabsorption, including coeliac disease, lactase deficiency and

bacterial overgrowth.

Irritable bowel syndrome: although the presence of bloating is not

used to define IBS, it is recognized as a common secondary feature.

Bloating is described by up to 90% of patients with IBS and is the

most bothersome symptom inup to 60%. Smoothmuscle relaxants,

such as peppermint oil, and antispasmodics, such as hyoscine,

mebeverine or dicycloverine (dicyclomine), have been shown to be

reasonably effective in bloating associated with IBS.

Eating disorders and obesity: bloating is a frequent feature of

anorexia, binge eating and obesity.

Ascites: bloating and distension secondary to ascites should

trigger a search for the underlying cause, such as ovarian cancer.

Aerophagia: repeated attempts at belching may cause aero-

phagia which can exacerbate the symptom of bloating.

MEDICINE 39:2 77

Flatulence: some individuals describe bloating in association

with excessive and/or malodorous flatulence. This is usually the

result of increased production of gas by colonic bacteria in

response to colonic dietary substrates. Peppermint oil has been

used to treat excess flatulence, although its major pharmaco-

logical effect appears to be as an antispasmodic.

Extra-intestinal signs of gastrointestinal disease

Anaemia: pallor of the conjunctivae points towards significant

anaemia. Iron-deficient anaemia is a frequent consequence of

serious GI disease. Colonic cancer and IBD frequently cause

anaemia.

Jaundice: clinically detectable jaundice may point to biliary

obstruction by metastatic colonic cancer.

Chronic low-grade fever may be present in a patient with

inflammatory bowel disease, diverticular abscess or, rarely,

colonic malignancy.

Organomegaly: features such as hepatomegaly or palpable lymph

nodes may represent metastatic spread of colonic carcinoma.

Clubbing of the digits has been associated with malabsorption,

IBD and polyposis syndromes.

Lethargy may be associated with anaemia, or with inflammatory

or functional bowel disease (it is very common in IBS).

Dermatological: syndrome-specific features may offer a clue to

diagnosis such as the distinctive mucosal pigmentation of Peutze-

Jeghers syndrome with concomitant multiple hamartomatous

polyps in the colon or features of scleroderma in patients with

secondary bacterial overgrowth and diarrhoea.

Extra-intestinal signs of inflammatory bowel disease (IBD)

Ophthalmic signs

Ophthalmic signs are seen most commonly in patients with

colitis, and more commonly in association with Crohn’s colitis

than ulcerative colitis. They usually occur in association with

active intestinal disease.

Episcleritis is the commonest ophthalmic manifestation of IBD

and presents with redness, discomfort and a conjunctivitis-like

syndrome.

Iritis and uveitis are less common and present with a loss of

visual acuity and a painful red eye.

Cutaneous signs

Erythema nodosum is the commonest dermatological condition

to occur in association with IBD. It is most commonly associated

with Crohn’s disease and affects around 15% of patients. It

presents as painful, raised, red lesions that occur most frequently

on the patient’s shins. It usually occurs in association with active

disease and parallels disease activity. Biopsy shows a subcuta-

neous septal panniculitis with a neutrophilic infiltrate.



SYMPTOMS AND SIGNS

Pyoderma gangrenosum occurs in approximately 2% of patients

with IBD and is more commonly associated with Crohn’s colitis.

The most characteristic lesion is a deep ulcer with a necrotic base

and a deep undermined purple edge, although rarer pustular and

bullous variates occur. The lesions are classically located on the

lower limb andmay be single ormultiple. Pyoderma also frequently

affects peri-stomal areas and other sites of surgery, suggesting that

pathergy is important in its aetiology. Histology shows a neutro-

philic dermatitis. A

FURTHER READING

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Neurogastroenterol Motil 2002; 14: 1e11.

Azpiroz F, Malagelada. Abdominal bloating. Gastroenterol 2005; 129:

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Chang L, Lee OY, Naliboff B, et al. Sensation of bloating and visible

abdominal distension in patients with irritable bowel syndrome. Am

J Gastroenterol 2001; 96: 3341e7.

Drossman DA, Corazziari E, Talley J, et al. Rome II: the functional

gastrointestinal disorders. Diagnosis, pathophysiology and treat-

ment: a multinational consensus. 2nd edn. USA: Degnon Associates,

2000.

Feldman M, Friedman LS, Brandt LJ. Sleisenger and Fordtran’s gastroin-

testinal and liver disease. Pathophysiology, diagnosis, management.

7th edn. London: WB Saunders, 2002.

Sandler RS, Stewart WF, Liberman JN, et al. Abdominal pain, bloating, and

diarrhea in the United States: prevalence and impact. Dig Dis Sci 2000;

45: 1166e71.

Thomas PD, Forbes A, Green J. Guidelines for the investigation of chronic

diarrhoea (Tests for malabsorption) 2nd edn. Gut 2003; 52(suppl V):

v1e15.



symptoms and signs of lower gastrointestinal disease

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