Intestine Methods of Examination

Inquiry

Complaints. The main complaints with intestinal diseases are pain, meteorism (inflation of the abdomen), motor dysfunction of the intestine (constipation and diarrhoea), and intestinal haemorrhage.

Pain. If the patient complains of pain in the abdomen, the following should be established: location of pain, its radiation, intensity, character, duration, and means by which it is lessened. The general signs by which in­testinal pain may be differentiated from gastric one are: (1) absence of regular dependence of pain on food taking; the only exception is inflamma­tion in the transverse colon (transversitis): pain develops immediately after meals; the pathogenesis of this pain is connected with reflex peristaltic con­tractions of the transverse colon when food enters the stomach; (2) close association of pain with defaecation: pain occurs before, during, and (rare­ly) after defaecation; (3) pain relief after defaecation or passage of gas.

Pain may be boring and spasmodic (intestinal colic). Colicky pain is characterized by short repeated attacks which arise and disappear quite of a sudden. Pain may very quickly change its location, the main site being

round the navel. Sometimes pain may arise in other areas of the abdomen. Boring pain is sometimes permanent; it intensifies during cough, especially if the mesenterium or peritoneum are involved. Pain is characteristic of in­flammatory diseases of the intestine. As inflammation extends onto the peritoneum, pain is attended by a pronounced muscular defence.

Exact location of the source of pain is very important. Pain in the right iliac region occurs in appendicitis, tuberculosis, cancer, or inflammation of the caecum (typhlitis). Acute pain in the left lower abdomen occurs in in­testinal obstruction and inflammation of the sigmoid (sigmoiditis). Pain in the umbilical region occurs in inflammation of small intestine (enteritis) and inflammation or cancer of the colon. Pain in the perineal region, and especially during defaecation (with the presence of blood in faeces), is characteristic of the rectum diseases (proctitis, cancer). Pain in intestinal pathology may radiate into the chest; pain associated with affection of the spleen angle of the descending large intestine radiates into the left side of the chest (it is sometimes mistaken for pain attacks of angina pectoris); col­ics of appendicitic origin radiate into the right leg.

In acute affection of the left portions of the large intestine (dysentery), pain radiates into the sacral area. Thermal procedures, spasmolytics, passage of gas, and emptying of the bowels can relieve pain or remove it completely.

Intestinal pain is caused by obstruction of intestinal patency and upset motor function. Intestinal pain is mostly caused by spasms (spasmodic contraction of smooth muscles; hence spastic pain), or by distension of the intestine by gases. Both mechanisms often become involved.

Spastic pain can be due to various causes. Individual predisposition to spastic contractions in general (vegetoneurosis) may be as important as ir­ritation originating in the intestine proper, e.g. in enteritis, colitis, in­testinal tumour, poisoning with arsenic or lead, and also in diseases of the central nervous system (posterior spinal sclerosis).

Pain arising due to intestinal distension by gases, and associated with tension and irritation of the mesentery, differs from spastic pain (1) by the absence of periodicity; it is long-standing and gradually lessens in prolong­ed inflation; and (2) by exact localization. In intestinal obstruction (com­plete or partial) colicky pain is combined with almost permanent pain in the abdomen. It is characterized by exact and permanent location (the um­bilical region and large intestine). The pain intensifies with intestinal peristalsis.

Appendicular colic first localizes round the navel and the epigastrium but in several hours (or even on the next day) it descends to the right iliac region where it intensifies gradually. Sometimes the pain arises straight in the right iliac region. ; '

366

Special Part

Chapter 7. Digestive System

367

Rectal colic, or tenesmus, is also known. It occurs in frequent and pain­ful tenesmus to defaecate and is associated with spasmodic contractions of the intestine and the sphincter ani. Only clots of mucus are sometimes ex­pressed instead of actual defaecation. Tenesmus occurs in dysentery and other inflammatory or ulcerous diseases, and in cancer of the rectum. Pain associated with defaecation depends on many factors. Pain preceding defaecation is associated with the disease of the descending colorf or sigmoid colon. Pain during defaecation is characteristic of haemorrhoids, anal fissures, and cancer.

Meteorism. The patient feels flatulence, inflation, and boring disten­sion of the abdomen. The causes of meteorism are (1) excessive gas forma­tion in the intestine due to ingestion of vegetable cellular tissue and easily fermented food (peas, beans, cabbage, etc.); (2) intestinal motor dysfunc­tion due to decreased tone of the intestinal wall or intestinal obstruction; (3) lowered absorbability of gases by the intestinal wall, the process of gas formation being normal; (4) aerophagia, i.e. excess swallowing of air, with its subsequent propulsion to the stomach and the intestine; (5) hysterical meteorism: the abdomen is rapidly inflated to the size of the abdomen of a pregnant woman at her last weeks; this nervous mechanism is very com­plicated.

When inquiring the patient, the physician should ask about the character of his nutrition and the site of abdomen inflation (the entire ab­domen or only its limited part may be inflated). If inflation is local, it is necessary to ask the patient whether or not inflation occurs always at one and the same area. In intestinal obstruction, the patient feels rumbling sounds inside the abdomen, feels movement of liquid in the intestine, and intense peristaltic movements above the point of obstruction.

Diarrhoea. Frequent and liquid stools is a common sign of intestinal pathology. Diarrhoea occurs in acute and chronic intestinal infections (enteritis, enterocolitis, sigmoiditis, proctitis), in various exogenous intox­ications (poisoning with arsenic or mercury), endogenous intoxications (uraemia, diabetes, gout), in endocrine disorders (adrenal dysfunction, thyrotoxicosis), and in hypersensitivity to some foods (allergy).

The mechanism of diarrhoea is very complicated. Different pathogenic factors may prevail in various pathological conditions. Accelerated move­ment of the liquefied food in the intestine due to peristalsis is among them. Almost undigested food can thus be evacuated. Another factor is disordered absorptive function of the intestine. Affection of the intestinal wall, disordered mechanisms regulating absorption, purgatives and upset water metabolism produce a marked change in the absorption process and are the cause of diarrhoea.

The third cause of liquid stools is inflammation of the intestine. Large

quantities of inflammatory secretion stimulating the intestinal receptors are released into the lumen of the intestine to intensify its peristalsis and to impair its absorptive function.

Paradoxical diarrhoea occurs in prolonged constipation due to mechanical irritation of the intestinal wall by hard faecal masses.

Upset equilibrium between the fermentative and putrefactive flora of the intestine is another important factor in the aetiology of diarrhoea. If fermentative flora prevails, fermentative dyspepsia occurs which is characterized by flatulence of the abdomen and semiliquid acid faeces (2— 3 stools a day); the faeces contain numerous gas bubbles, numerous starch grains, vegetable cellular tissue, and iodophilic microbes. Fermentative dyspepsia develops in connection with deranged digestion of car­bohydrates, if they are ingested in excess.

Putrid dyspepsia more often occurs in secretory hypofunction of the stomach. The absence of bactericidal action of gastric juice is connected with the absence of hydrochloric acid; rapid passage of insufficiently digested food from the stomach to the intestine has a negative effect in the first instance on digestion of proteins. This in turn provokes putrid dyspep­sia. It is characterized by liquid dark excrements containing clots of un­digested food; the faeces react alkaline and have a foul putrid smell. Microscopy of faeces reveals much fats, muscular fibres with vivid transverse and longitudinal striation and even ends (creatorrhoea). The content of organic compounds in the faeces is increased. The iodophilic flora is absent.

Diarrhoea occurring in organic affections of the large intestine is most­ly of the inflammatory character. It is not copious, nor does it produce strong negative effect on the patient's general condition (as compared with affections of the small intestine which is attended by profuse diarrhoea associated with deranged motor and absorption function of the intestine). The pronounced disorder in digestion causes some metabolic disorders in the patient (impaired absorption of proteins, iron, vitamins, and elec­trolytes).

Obstipation. This is obstinate constipation during which faeces are long retained in the intestine (for more than 48 hours). But the duration of con­stipation is only relative, because in many cases it is not the result of pathology but of the living conditions and nutrition. If vegetable food dominates in the diet, the subject may defaecate two or three times a day. Stools become rarer if the diet is rich in meat. A radical change in nutrition can remove constipation. Limited mobility of the subject, hunger, and ir­regular defaecations (during the day) may prolong pauses between defaeca­tion. The main factor determining defaecation is the condition of intestinal motor function. Bowel contents are retained in the large intestine and the rectum during constipation.

368

Special Part ^f

Chapter 7. Digestive System

369

Organic and functional constipation is differentiated. Organic con­stipation is usually associated with mechanical obstruction, such as nar­rowing of the intestinal lumen due to a tumour, scar, adhesion, and also abnormalities in the intestine (megacolon, dolichosigmoid, megasigmoid, diverticulosis).

Functional constipation is subdivided into: (1) alimentary constipation; it occurs due to ingestion of easily assimilable foods, which leave small residue and normally stimulate peristalsis of the intestine by irritating its nervous receptors; (2) neurogenic constipation due to dysfunction of the intramural nervous apparatus or vagus nerve; these are the so-called dyskinetic constipation, caused by the reflex action on the intestinal motor function of another affected organ (cholecystitis, adnexitis, prostatitis, etc.), or by organic affections of the central nervous system (tumours of the brain, encephalitis, posterior spinal sclerosis); (3) constipation associated with inflammatory affections, mainly of the large intestine (dysentery); (4) toxic constipation occurring in exogenous poisoning with lead, morphine, or cocaine; (5) constipation of endocrine aetiology, occur­ring in thyroid or pituitary hypofunction; (6) constipation caused by lack of physical exercise; (7) constipation caused by flaccidity of the prelum.

Intestinal haemorrhage often occurs in ulcerous affections of the alimentary system. It develops in the presence of tumour, protozoal and helminthic invasions, acute infections (typhoid fever, bacillary dysentery), in thrombosis of mesenteric vessels, ulcerous non-specific colitis, etc.

Anamnesis. The patient should be inquired thoroughly about his nutri­tion from his early childhood till the onset of the disease (especially directly before the disease), about poisonings in the past history and hypersensitivi-ty to some feods. It is necessary to find out if the patient's meals are regular, if the food is varied, and if the patient smokes or drinks alcohol. Information on the past diseases of the intestine and also on pathology of other organs is sometimes decisive for establishing the cause of the present affection.

Some functional disorders of the intestine can be associated with oc­cupation (lead or arsenic poisoning, constipation due to frequent suppres­sion of tenesmus to defaecate).

Physical Examination