Gastrointestinal (GI) symptoms and disorders are quite common. History and physical examination are often adequate to make a disposition in patients with minor complaints; in other cases, testing is necessary.
Ambulatory 24-hour esophageal pH monitoring with or without intraluminal impedance testing is currently the most common test for quantifying gastroesophageal reflux (see the American College of Gastroenterology's 2022 Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease). The principal indications are
Abdominal pain is common and often inconsequential. Acute and severe abdominal pain, however, is almost always a symptom of intra-abdominal disease. It may be the sole indicator of the need for surgery and must be attended to swiftly: Gangrene and perforation of the gut can occur < 6 hours from onset of symptoms in certain conditions (eg, interruption of the intestinal blood supply due to a strangulating obstruction or an arterial embolus). Abdominal pain is of particular concern in patients who are very young or very old and those who have HIV infection or are taking immunosuppressants (including corticosteroids).
The anal canal begins at the anal verge and ends at the anorectal junction (pectinate line, mucocutaneous junction, dentate line), where there are 8 to 12 anal crypts and 5 to 8 papillae. The canal is lined with anoderm, a continuation of the external skin. The anal canal and adjacent skin are innervated by somatic sensory nerves and are highly susceptible to painful stimuli. Venous drainage from the anal canal occurs through the caval system, but the anorectal junction can drain into both the portal and caval systems. Lymphatics from the anal canal pass to the internal iliac nodes, the posterior vaginal wall, and the inguinal nodes. The venous and lymphatic distributions determine how malignant disease and infection spread.
A variety of foreign bodies may enter the gastrointestinal (GI) tract intentionally or accidentally. Many foreign bodies pass through the GI tract spontaneously, but some become impacted, causing symptoms and sometimes complications. The role of imaging in the management of foreign body ingestion is not standardized. Nearly all impacted objects can be removed endoscopically, but surgery is occasionally necessary. Timing of endoscopy varies depending on the type of foreign body ingested.
The swallowing apparatus consists of the pharynx, upper esophageal (cricopharyngeal) sphincter, the body of the esophagus, and the lower esophageal sphincter (LES). The upper third of the esophagus and the structures proximal to it are composed of skeletal muscle; the distal esophagus and LES are composed of smooth muscle. These components work as an integrated system that transports material from the mouth to the stomach and prevents its reflux into the esophagus. Physical obstruction or disorders that interfere with motor function ( esophageal motility disorders) can affect the system.
Acid is secreted by parietal cells in the proximal two thirds (body) of the stomach. Gastric acid aids digestion by creating the optimal pH for pepsin and gastric lipase and by stimulating pancreatic bicarbonate secretion. Acid secretion is initiated by food: the thought, smell, or taste of food effects vagal stimulation of the gastrin-secreting G cells located in the distal one third (antrum) of the stomach. The arrival of protein to the stomach further stimulates gastrin output. Circulating gastrin triggers the release of histamine from enterochromaffin-like cells in the body of the stomach. Histamine stimulates the parietal cells via their H2 receptors. The parietal cells secrete acid, and the resulting drop in pH causes the antral D cells to release somatostatin, which inhibits gastrin release (negative feedback control).
Gastroenteritis is inflammation of the lining of the stomach and small and large intestines. Most cases are infectious, although gastroenteritis may occur after ingestion of drugs, medications, and chemical toxins (eg, metals, plant substances). Acquisition may be foodborne, waterborne, person-to-person spread, or occasionally through zoonotic spread. In the United States, an estimated 1 in 6 people contracts foodborne illness each year. Symptoms include anorexia, nausea, vomiting, diarrhea, and abdominal discomfort. Diagnosis is clinical or by stool culture, although polymerase chain reaction testing and immunoassays are increasingly used. Treatment is supportive and directed at symptoms, but some parasitic and some bacterial infections require specific anti-infective therapy.
Gastrointestinal (GI) bleeding can originate anywhere from the mouth to the anus and can be overt or occult. The manifestations depend on the location and rate of bleeding. (See also Varices and Vascular Gastrointestinal Lesions.)
Inflammatory bowel disease (IBD), which includes Crohn disease and ulcerative colitis, is a relapsing and remitting condition characterized by chronic inflammation at various sites in the gastrointestinal tract, which results in diarrhea and abdominal pain.
Irritable bowel syndrome is characterized by recurrent abdominal discomfort or pain with at least two of the following characteristics: relation to defecation, association with a change in frequency of stool, or association with a change in consistency of stool. The cause is not known, and the pathophysiology is incompletely understood. Diagnosis is clinical. Treatment is symptomatic, consisting of dietary management and drugs, including anticholinergics and agents active at serotonin receptors.
Anal cancer accounts for an estimated 9760 cases and about 1870 deaths in the United States annually ( 1). The main symptom is bleeding with defecation. Diagnosis is by endoscopy. Treatment options include excision and chemotherapy and radiation therapy.