Symptoms of lower gastrointestinal disease

CHAPTER 10 Symptoms of lower gastrointestinal disease





Introduction


Gastrointestinal symptoms are very common within the general population (Thompson et al., 2003). There is a high prevalence of rectal bleeding (Crossland and Jones, 1995; Thompson et al., 2000), change in bowel habit (Everhart et al., 1989) and abdominal pain (Sandler, 1990). Since any one of these symptoms alone can be due to benign, transient disease, symptom complexes are more useful for predicting serious pathology (Thompson et al., 2007). In the UK, this has led to the ‘two week wait guidelines’ for suspected cancer (Department of Health, 2000). This means that patients with symptoms most predictive of colorectal cancer (Table 10.1) must be seen within 2 weeks from the date of referral.


Table 10.1 Criteria for urgent referral for suspected colorectal cancer under the two-week rule
























Sign, symptom or combination Age threshold
Rectal bleeding with a change in bowel habit to looser stools and/or increased frequency of defecation persistent for 6 weeks Over 40 years
A definite right-sided abdominal mass All ages
A definite palpable rectal (not pelvic) mass All ages
Change of bowel habit to looser stools and/or increased frequency of defecation, without rectal bleeding and persistent for 6 weeks Over 60 years
Rectal bleeding persistently without anal symptoms Over 60 years
Iron deficiency anemia without an obvious cause (Hb<11 g/dl in men or <10 g/dl in postmenopausal women) No age criterion

This chapter will explore symptoms and symptom complexes of lower gastrointestinal disease, the possible diagnosis and the investigation performed for each symptom group.



Rectal bleeding


Bleeding from the gastrointestinal tract can be overt or occult. With overt rectal bleeding, the blood is recognized and is usually noticed on defecation. If this is the case, the origin of the bleeding is usually in the left colon or distal transverse colon. If the bleeding is occult, the blood loss is not recognized in the stool and the patient presents with anemia.


When a patient presents with rectal bleeding, there are features that can help locate the source of the bleeding, such as the color of the blood. Bright red rectal bleeding tends to originate from a distal source such as the rectum, whereas dark red blood tends to originate from a more proximal source but within the left colon or distal transverse colon. Another feature is whether the blood is separate to the stool or mixed in when it is passed. If the blood is separate to the stool, the patient notices it on the toilet paper or in the water in the toilet bowl, this usually suggests a very distal source such as hemorrhoids. If blood has had time to mix in with the stool, it suggests a more proximal source of bleeding.


Coexisting symptoms are also very important. A change in bowel habit to looser stools coupled with rectal bleeding is a symptom complex with a high predictive value for cancer (see above) or colitis. Anal pain may suggest a fissure. Change in bowel habit to constipation may merely mean that constipation has exacerbated hemorrhoids. Common combinations of symptoms associated with rectal bleeding, the possible causes and appropriate investigations are detailed below.



Dec 26, 2015 | Posted by in GASTROINTESTINAL IMAGING | Comments Off on Symptoms of lower gastrointestinal disease
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