1. Introduction / W.G. Thompson

The key to accurate diagnosis and effective management of gastrointestinal problems is flawless history-taking. Since up to 50% of gastrointestinal disorders are associated with no anatomical change, no physical findings and no positive test result, diagnosis and therapy must often be based on the medical interview. The gastrointestinal history must include an accurate description of the symptom itself, a past history of gastrointestinal disorders or surgery, a meticulous search for symptoms that might suggest organic disease (such as gastrointestinal hemorrhage, anemia or weight loss) and finally, a careful assessment of the patient's psychosocial state, with particular attention directed toward traumatic events or concerns associated with the onset of the patient's complaints. 

The physician should determine the time of onset of the symptom, its occurrence in the past, its periodicity, its location and radiation if appropriate, its aggravating and relieving factors, and its relationship to other symptoms. A review of past history should include not only any previous gastrointestinal surgery or diseases, but also systemic illnesses (such as diabetes or severe cardiovascular disease) that might affect the gut. One should pay particular attention to such symptoms as gastrointestinal hemorrhage, profound weight loss, voluminous diarrhea or episodes of extreme abdominal pain, which might indicate organic disease. Similarly, such phenomena as anemia, fever or incapacity to work may indicate a more serious gastrointestinal disorder demanding treatment and follow-up. A family history of inflammatory bowel disease or bowel cancer may indicate a more careful investigation as well. 

When considering a gastrointestinal complaint, the astute physician cannot ignore the patient's psyche. Many studies establish that those who bring gastrointestinal complaints to a physician, even if they are organic in nature, frequently have psychosocial disabilities. Failure to identify and manage the patient's reaction to his or her psychosocial environment (whether it be hostility toward a spouse, an abnormal fear of cancer or a profound loss) may lead to an unsatisfactory therapeutic outcome.

The following is a synopsis of the common gastrointestinal symptoms. These notes include a description of the symptom itself, a word about how the symptom is generated, the important historical features and associated physical findings, and a brief approach to diagnosis and management. These serve as introductory comments; greater detail can be found throughout the text in discussions of specific diseases. The final section of this chapter presents a sequential approach to the examination of the abdomen.