Confusing or Ambiguous Upper Gut Symptoms
By choosing the appropriate test, a doctor can make a precise diagnosis of a structural upper gut disorder, such as esophagitis or peptic ulcer, by recognizing the diseased area. The patient’s history provides the information that permits the doctor to choose the right test.
In the case of the disorders of gastrointestinal function, such as dyspepsia or non-cardiac chest pain, there is no structural abnormality and no diagnostic test. Hence, diagnosis of these disorders depends even more upon how the patient describes his or her symptoms.
Many people use words to describe their gut symptoms that are vague or misleading. Since these terms are unhelpful in identifying the problem they should be avoided or explained carefully. The following are some examples.
A medical dictionary defines indigestion as "incomplete or imperfect digestion, usually accompanied by one or more of the following symptoms: pain, nausea and vomiting, heartburn and acid regurgitation, accumulation of gas and belching." I have even heard the term used to denote diarrhea and constipation. Apparently indigestion can include almost any gut symptom. Consequently the term is of little use to a doctor trying to analyze a patient’s history in order to make a diagnosis or plan appropriate tests. For this reason the term is best avoided.
Dictionaries state that dyspepsia is a synonym for indigestion, which again is unhelpful. Gastroenterologists have defined dyspepsia more narrowly as a "pain or discomfort centered in the upper abdomen." Such a pain is found in peptic ulcer disease or nonulcer dyspepsia and must be differentiated from pains of other upper abdominal complaints. Dyspepsia is a symptom complex or diagnosis recognized by doctors, but unhelpful when trying to describe symptoms.
Thus neither indigestion nor dyspepsia are of any diagnostic use, and a person should avoid these terms in a medical interview.
It is preferable to describe in a few words the characteristics of the actual pain, discomfort, or gastrointestinal upset in order to help doctors determine what part of the gut is dysfunctioning and what the diagnostic possibilities might be.
Every human gastrointestinal tract contains gas that occasionally escapes through the mouth or anus. However, gas has come to mean different things to different people.
Someone who belches or burps feels "full of gas."
Another person suffering the release of gas from the other end may use the term gas euphemistically, too embarrassed to describe gas escaping from the anus – and too discreet to use a slang term.
Still another may feel bloated or distended and say they are "full of gas." Worsening during the day, the connection of this symptom with intestinal gas is poorly understood.
Noises from the stomach, frequently described as growling or grumbling sounds, are known medically as borborigmi. These sounds are the result of air gurgling with liquids as it passes through the ever-moving intestines.
Fortunately these gas scenarios are seldom signs of serious disease. Nevertheless, they can be annoying and worrying, so it is important that the doctor know how the symptoms of gas manifest so he or she can interpret the complaint.
Nausea is "the unpleasant feeling of sickness that often precedes vomiting." It’s not that nausea is imprecise – we all know what it feels like.
The problem is that nausea is associated with so many disorders and circumstances that by itself it has no diagnostic significance. Seasickness or the nausea of pregnancy are obvious only if the doctor knows the appropriate history. Nausea very often, but not always, precedes or accompanies vomiting.
The disorders causing nausea are as varied as motion sickness (middle ear), intestinal obstruction, diseases affecting the brain, drug side effects, hormonal changes, and fright or anxiety states. Sometimes the sight of a food can nauseate.
If a person’s main complaint is nausea, only the associated circumstances, symptoms, and medications can help the doctor search for the cause.
Vomiting seems an easy symptom to understand. It is the return of gastric contents including food and gastric acid from the stomach through the mouth.
However, there are some lesser-known symptoms sometimes confused with vomiting. Regurgitation of acid and food into the esophagus may occur due to a weakness in the lower esophageal sphincter. This is called gastroesophageal reflux – the fundamental abnormality underlying GERD. Unlike vomiting, the regurgitated material returns to the stomach without being ejected through the mouth. In both cases the person may experience heartburn as a result of the acid in the esophagus.
A rarer type of regurgitation is known as rumination. Here a person regurgitates the meal from the stomach into the mouth and then swallows it again with neither discomfort nor concern. The meal is returned promptly before it is mixed with acid, so the person suffers no heartburn.
Sometimes excess production of saliva by glands in the mouth may accompany upper abdominal symptoms such as nausea or heartburn. Unlike vomiting, the saliva does not burn and is usually swallowed. This is known as waterbrash.
In many people, the junction between the esophagus (food pipe) and stomach "herniates" up through the diaphragm into the chest cavity. This phenomenon may be temporary or permanent, and is often cited as one of the causes of gastroesophageal reflux disease (GERD). However, hiatal hernia [also referred to as hiatus hernia] is an anatomical abnormality, not a symptom, and its presence or absence does not equate with the symptoms of GERD.
Rather than describing "my hiatal hernia," it is more precise to describe the sensation itself. The most common symptom is heartburn – a burning sensation behind the breastbone. A careful description of heartburn, and noticing what makes it worse (lying down, large meals, effort, etc) is very helpful to a physician who will diagnose it as GERD, not hiatal hernia.
There are many causes of chest pain, some very serious, and few are connected to the gut.
The primary concern is that chest pain might be due to heart disease. That is why it is very important to be as precise as possible about the nature of the symptom. Is the pain worse after exercise? Does it occur when walking a certain distance, disappear with rest, and then recur when the certain distance is walked again?
Pain resulting from injury to the muscles or bones of the chest wall will worsen with certain movements of the trunk. Pleurisy, an inflammation of the lining of the lung, will be sharply worse with inhaling or exhaling.
If the pain is due to esophageal disease, then a relationship with swallowing, with meals, or an association with acid regurgitation is usually present. Characteristically, acid-related pain is relieved by antacids and most dramatically by the proton pump inhibitors.
The details surrounding upper gut symptoms are often very important in arriving at a correct and timely diagnosis. Therefore describe symptoms such as chest pain with care. None of these are specific, however, and further evaluation is always required – cardiac disease must be ruled out. Your life could depend upon it.