Fecal incontinence is the involuntary discharge of rectal contents and is most often caused by

neuromuscular disorders or structural anorectal problems.

Overflow diarrhea may occur in nursing home patients due to fecal impaction that is readily detectable

by rectal examination.

CONSTIPATION

Definition

Constipation refers to bowel movements that are infrequent or hard to pass.

Obstipation is intractable constipation that has become refractory to cure or control. There is inability to

pass any feces or flatus.

Tenesmus is stated by patients as the unpleasant symptom that there remains something to evacuate

from the rectum despite passing a stool. It is often painful. It indicates rectal inflammation.

Etiology of constipation

Functional (nonorganic)

or retentive

Includes constipation due to fecal withholding behaviors and when all organic causes have been

ruled out

Anatomic causes Include anal stenosis or atresia, anteriorly displaced anus, imperforate anus, intestinal stricture, and

anal stricture

Abnormal musculature Related causes include prune belly syndrome, gastroschisis, Down syndrome, and muscular

dystrophy

Intestinal nerve

abnormality

Related causes include Hirschsprung disease, pseudo-obstruction, intestinal neuronal dysplasia,

spinal cord defects, tethered cord, and spina bifida

Drugs Like anticholinergics, narcotics, antidepressants, lead, and vitamin D intoxication

Metabolic and

endocrine causes

Like hypokalemia, hypercalcemia, hypothyroidism, diabetes mellitus (DM), or diabetes insipidus

Other causes Include celiac disease, cystic fibrosis, cow milk protein allergy, inflammatory bowel disease,

scleroderma among others

DYSPEPSIA

Definition

Rome III criteria for dyspepsia

≥1 of the following:

Postprandial fullness

Early satiation (inability to finish a normal-sized meal)

Epigastric pain or burning

Table 5C.4: Causes of dyspepsia.

Luminal gastrointestinal tract

Chronic gastric or intestinal ischemia

Food intolerance

Functional dyspepsia

Gastroesophageal reflux disease

Gastric or esophageal neoplasms

Gastric infections (e.g. cytomegalovirus, fungus, tuberculosis, and syphilis)

Gastroparesis (e.g. diabetes mellitus, postvagotomy, scleroderma, chronic intestinal pseudo-obstruction, postviral, and

idiopathic)

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Irritable bowel syndrome

Peptic ulcer disease

Parasites (e.g. Giardia lamblia, Strongyloides stercoralis)

Medications

Acarbose, aspirin, other nonsteroidal anti-inflammatory drugs (including cyclooxygenase-2 selective agents), colchicine, digitalis

preparations, estrogens, ethanol, glucocorticoids, iron, levodopa, niacin, narcotics, nitrates, orlistat, potassium chloride, quinidine,

sildenafil, and theophylline

Pancreaticobiliary disorders

Biliary pain: cholelithiasis, choledocholithiasis, and sphincter of Oddi dysfunction

Chronic pancreatitis

Pancreatic neoplasms

Systemic conditions

Adrenal insufficiency, congestive heart failure, diabetes mellitus, hyperparathyroidism, myocardial ischemia, pregnancy, renal

insufficiency, and thyroid disease

DYSPHAGIA

Definition

Dysphagia, from the Greek dys (difficulty, disordered) and phagia (to eat), refers to the sensation that

food is hindered in its passage from the mouth to the stomach.

Table 5C.5: Causes of oropharyngeal dysphagia.

Neuromuscular causes Structural causes

Amyotrophic lateral sclerosis (ALS)

Multiple sclerosis

Muscular dystrophy

Myasthenia gravis

Parkinson’s disease

Polymyositis or dermatomyositis

Stroke

Thyroid dysfunction

Carcinoma

Infections of pharynx or neck

Osteophytes or other spinal disorders

Prior surgery or radiation therapy

Proximal esophageal web

Plummer-Vinson syndrome

Thyromegaly

Zenker’s diverticulum

Table 5C.6: Common causes of esophageal dysphagia.

Motility (neuromuscular) disorders Structural (mechanical) disorders

Primary disorders:

Achalasia

Diffuse esophageal spasm

Hypertonic lower esophageal sphincter (LES)

Ineffective esophageal motility

Nutcracker (high pressure esophagus).

Intrinsic factors:

Carcinoma and benign tumors

Diverticula

Eosinophilic esophagitis

Esophageal rings and webs (except Schatzki ring)

Foreign body

Lower esophageal (Schatzki) ring

Medication-induced stricture

Peptic stricture

Secondary disorders:

Chagas disease

Reflux-related dysmotility

Scleroderma and other rheumatological disorders

Extrinsic factors:

Mediastinal mass

Spinal osteophytes

Vascular compression

ODYNOPHAGIA

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Definition

Odynophagia, or painful swallowing, is a specific feature for esophageal involvement. It usually reflects

an inflammatory process in the esophageal mucosa.

Table 5C.7: Causes of odynophagia.

Caustic ingestion: Acid alkali

Pill-induced injury:

Alendronate and other bisphosphonates

Aspirin and other NSAIDs

Iron preparations

Potassium chloride (especially slow release form)

Tetracycline and its derivatives

Quinidine

Zidovudine

Infectious esophagitis:

Viral: Cytomegalovirus, Epstein-Barr virus, herpes simples virus, and human immunodeficiency virus

Bacteria: Mycobacteria (tuberculosis or Mycobacterium avium complex)

Fungal: Candida albicans, histoplasmosis

Protozoan: Cryptosporidium, Pneumocystis

Severe reflux esophagitis

Esophageal carcinoma

PAIN IN ABDOMEN

The history of a patient with abdominal pain includes determining whether the pain is acute or chronic

and a detailed description of the pain and associated symptoms, which should be interpreted with other

aspects of the medical history.

Acute versus Chronic Pain

There is no strict time period that will classify the differential diagnosis unfailingly. A clinical judgment

must be made that considers whether this is an accelerating process, one that has reached a plateau, or

one that is long-standing but intermittent. Patients with chronic abdominal pain may present with an

acute exacerbation of a chronic problem or a new and unrelated problem. Pain of less than a few days’

duration that has worsened progressively until the time of presentation is clearly “acute”. Pain that has

remained unchanged for months or years can be safely classified as chronic. Pain that does not clearly

fit either category might be called subacute and requires consideration of a broader differential than

acute and chronic pain.

Description of Pain

Pain is discussed under following headings:

Location and radiation: the location of abdominal pain helps narrow the differential diagnosis as

different pain syndromes typically have characteristic locations (described in the tables below). For

example, pain involving the liver or biliary tree is generally located in the right upper quadrant, but it

may radiate to the back or epigastrium. Because hepatic pain only results when the capsule of the

liver is “stretched”, most pain in the right upper quadrant is related to the biliary tree. Pain radiation is

also important: the pain of pancreatitis classically bores to the back, while renal colic radiates to the

groin.

Temporal elements: the onset, frequency, and duration of the pain are helpful features. The pain of

pancreatitis may be gradual and steady, while perforation and resultant peritonitis begins suddenly

and is maximal from the onset.

Quality: the quality of the pain includes determining whether the pain is burning or gnawing, as is

typical of gastroesophageal reflux and peptic ulcer disease, or colicky, as in the cramping pain of

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gastroenteritis or intestinal obstruction.

Severity: the severity of the pain generally is related to the severity of the disorder, especially if

acute in onset. For example, the pain of biliary or renal colic or acute mesenteric ischemia is of high

intensity, while the pain of gastroenteritis is less marked. Age and general health may affect the

patient’s clinical presentation. A patient taking corticosteroids may have significant masking of pain,

and older adult patients often present with less intense pain.

Precipitants or palliation: determining what precipitates or palliates the pain can help narrow the

differential. The pain of chronic mesenteric ischemia usually starts within one hour of eating, while

the pain of duodenal ulcers may be relieved by eating and recur several hours after a meal.

Position/posture: the pain of pancreatitis is classically relieved by sitting up and leaning forward.

Peritonitis often causes patients to lie motionless on their backs because any motion causes pain. Obtaining a history of pain occurring in relationship to eating lactose- or gluten-containing foods may

be helpful in identifying sensitivities to these food constituents. Patients with foodborne illness may

become ill after eating certain foods.

Associated Symptoms

Other gastrointestinal symptoms: we ask about associated nausea, vomiting, diarrhea,

constipation, hematochezia, melena, and changes in stool (e.g. change in caliber). For patients with

right upper quadrant pain or concern for liver disease, we also ask about jaundice and changes in the

color of urine and stool. The bowel habit is an important part of the history for chronic abdominal pain. While many organic lesions can result in chronic diarrhea, irritable bowel syndrome (IBS) often

presents with swings between diarrhea and constipation, a pattern that is much less likely with organic

disease.

Genitourinary symptoms: patients with symptoms such as dysuria, frequency, and hematuria are

more likely to have a genitourinary cause for their abdominal pain.

Constitutional symptoms: symptoms such as fever, chills, fatigue, weight loss, and anorexia would

be concerning for infection, malignancy, or systemic illnesses [e.g. inflammatory bowel disease (IBD)].

Cardiopulmonary symptoms: symptoms, such as cough, shortness of breath, orthopnea, and

exertional dyspnea suggest a pulmonary or cardiac etiology. Orthostatic hypotension may indicate

early shock or be associated with adrenal insufficiency.

Other: patients with diabetic ketoacidosis will have symptoms of polyuria and thirst. Patients with

suspected IBD should be asked about extraintestinal manifestations.

Other Medical History

Specific questions for women: women should be screened for sexually transmitted diseases and

risks for pelvic inflammatory disease (e.g. new or multiple partners). Premenopausal women should

be asked about their menstrual history (last menstrual period, last normal menstrual period, and cycle

length) and use of contraception. They should also be asked about vaginal discharge or bleeding,

dyspareunia, or dysmenorrhea, as these symptoms suggest a pelvic pathology.

Past medical history: a history of surgeries and procedures should be obtained to assess risk for

differing etiologies (e.g. a history of abdominal surgery is a risk factor for obstruction). A history of

cardiovascular disease (CVD) or multiple risk factors for CVD in a patient with epigastric pain raises

concern for a myocardial ischemia.

Medications: a comprehensive medication list should be elicited as this can inform the differential.

For example, patients taking high doses of nonsteroidal anti-inflammatory drugs (NSAIDs) are at risk

for gastropathy and peptic ulcer disease. Patients with recent antibiotic use or hospitalization are at

risk for Clostridioides (formerly Clostridium) difficile. Patients on chronic steroids are at risk for adrenal

insufficiency and may be immunosuppressed with atypical presentations of abdominal pain.

Other history: Alcohol—it is important to ask about alcohol intake to assess for the possibility of liver

disease and pancreatitis.

Family history: family history should be asked as appropriate based on other history. For example,

patients with history concerning for IBD or cancer should also be asked about family history.

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Travel history: a travel history is important to elicit in patients with symptoms consistent with

gastroenteritis or colitis (e.g. nausea, vomiting, and diarrhea) to consider infectious etiologies.

Sick contacts: often patients are in contact with someone with gastroenteritis before having similar

symptoms. Patients with foodborne illness may also have close contact with similar illness.

Site of Pain and Possible Etiology

Causes of right upper quadrant (RUQ) abdominal pain.

RUQ Clinical features

Biliary

Biliary colic Intense dull discomfort located in the RUQ or epigastrium. Associated with nausea, vomiting, and

diaphoresis. Generally lasts at least 30 minutes plateauing within 1 hour. Benign on abdominal

examination

Acute cholecystitis Prolonged (>4–6 hours), RUQ or epigastric pain, fever. Patients will have abdominal guarding and

Murphy’s sign

Acute cholangitis Fever, jaundice, and RUQ pain

Sphincter of Oddi

dysfunction

RUQ pain similar to other biliary pain

Hepatic

Acute hepatitis RUQ pain with fatigue, malaise, nausea, vomiting, and anorexia. Patients may also have jaundice, dark

urine, and light-colored stools

Perihepatitis (FitzHugh-Curtis

syndrome)

RUQ pain with a pleuritic component. Pain is sometimes referred to the right shoulder

Liver abscess Fever and abdominal pain are the most common symptoms

Budd–Chiari

syndrome

Symptoms include fever, abdominal pain, abdominal distension (from ascites), lower extremity edema,

jaundice, gastrointestinal bleeding, and/or hepatic encephalopathy

Portal vein

thrombosis

Symptoms include abdominal pain, dyspepsia, or gastrointestinal bleeding

Causes of epigastric abdominal pain

Epigastric Clinical features

Acute myocardial infarction May be associated with shortness of breath and exertional symptoms

Acute pancreatitis Acute onset, persistent upper abdominal pain radiating to the back

Chronic pancreatitis Epigastric pain radiating to the back

Peptic ulcer disease Epigastric pain or discomfort is the most prominent symptom

Gastroesophageal reflux

disease

Associated with heartburn, regurgitation, and dysphagia

Gastritis/gastropathy Abdominal discomfort/pain, heartburn, nausea, vomiting, and hematemesis

Functional dyspepsia The presence of one or more of the following: postprandial fullness, early satiation, epigastric

pain, or burning