Main complaints and pain detailing
Patients with intestinal diseases most frequently present with five groups of complaints: abdominal pain, bloating (flatulence), diarrhea, constipation, and the presence of admixtures in the stool (blood, mucus).
Pain is a leading symptom that requires careful questioning. The character of the pain can be dull, sharp, cramping (colicky), or bursting. When taking the history, it is necessary to determine:
- Localization and migration: for example, the classic Kocher's sign in acute appendicitis (shift of pain from the epigastrium to the right iliac region).
- Chronology: sudden or gradual onset, duration of the attack, diurnal dynamics.
- Association with provoking factors: food intake, physical exertion, or body position.
Important diagnostic marker: reduction of pain after defecation is typical for functional disorders such as irritable bowel syndrome (IBS).
Diarrheal syndrome
During questioning, it is important to immediately differentiate true diarrhea from fecal incontinence. Diagnosis is based on assessing stool frequency, its character (color, consistency), and association with triggers (food, antibiotics, laxatives, contact with infectious patients).
Chronic diarrhea is a polyetiological condition. Its main causes include:
- Inflammatory bowel diseases (IBD): Crohn's disease, ulcerative colitis.
- Iatrogenic factors: laxative abuse, iron supplements, or antibiotics (risk of developing pseudomembranous colitis caused by Clostridioides difficile).
- Malabsorption syndrome: celiac disease, pancreatic pathology.
- Extraintestinal causes: endocrine disorders (thyrotoxicosis, diabetes mellitus), enzymopathies, allergic reactions, and parasitic infestations.
By mechanism of development, it is customary to distinguish secretory, osmotic, exudative, and motor diarrhea. When an infectious etiology is suspected, non-infectious factors must be excluded: laxative use in the preceding 48 hours, chemotherapy, enteral nutrition, and recent abdominal surgery.
Constipation syndrome
Constipation can be either an independent leading complaint (in 5% of patients) or accompany other pathologies (e.g., exacerbation of duodenal ulcer). The underlying cause is impaired motility, mechanical obstacles, or failure of the defecation reflex.
Pathogenetically, three types of constipation are distinguished:
- Spastic: occurs due to hypertonus of smooth muscle. Causes include local lesions (colitis, IBS), anorectal pathology (anal fissure), or psychogenic factors. Manifested by pain and fragmented hard stool ("sheep feces" appearance).
- Atonic: a consequence of intestinal hypotonia against the background of hypodynamia, irrational diet, antacid intake, or CNS lesions. Characterized by dull bursting pain and pronounced flatulence.
- Mechanical: caused by a physical barrier (tumors, adhesions, developmental anomalies). Accompanied by active peristalsis in the early stages and rapid increase in intoxication.
Pediatric note: in infants, a tendency to constipation is physiological and anatomically explained by the relatively greater length of the intestine compared to adults.
Red flag symptoms and pathological admixtures
The appearance of blood or mucus in the feces is a strict indication for in-depth instrumental examination (rectosigmoidoscopy, stool analysis). Suspicion of IBD arises in the presence of chronic symptoms (more than 4 weeks) including bloody diarrhea, abdominal pain, and tenesmus (painful false urges).
Another frequent accompanying symptom is weight loss. For differential diagnosis, the physician determines not only the period over which weight was lost, but also the patient's eating behavior: diet composition, enjoyment of food, preservation of appetite, as well as the presence of fever and dyspeptic symptoms (nausea, vomiting).
Types of constipation are easily remembered by the acronym SAM: Spastic (tone is increased), Atonic (tone is decreased), Mechanical (there is an obstruction).
Class and exam questions
How to clinically distinguish organic diarrhea from functional during questioning?
A key differential sign is nocturnal defecation. Its presence indicates organic bowel disease, whereas it is not characteristic of functional disorders.
In which cases is Clostridioides difficile testing indicated?
Testing is performed for newly onset diarrhea (loose stools of type 6–7 on the Bristol scale at least 3 times a day) within 24 hours without other obvious causes, especially in the context of recent antibiotic therapy or hospital stay.
What symptoms form the criteria for suspected IBD?
Symptoms lasting longer than 4 weeks should raise suspicion: diarrhea (especially with blood admixtures), tenesmus, and severe abdominal pain.
What else to study on this topic
- Semiotics of stool changes in young children (simple and toxic dyspepsia, alimentary deficiency).
- Classification and systemic manifestations of intestinal dysbiosis.
- Rome criteria for functional constipation and complaint detailing algorithm.
- Pathophysiological classification of diarrhea (secretory, osmotic, exudative, motor).
- History-taking algorithm for weight loss in gastroenterological patients.
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