Medical students are taught that patients who don’t cry with their eyes may well cry with their guts. We are all used to tears, blushes, sweating, panting and breathlessness in worried and anxious patients, and the cause of such symptoms is likely to be emotional turmoil or plain misery. But patients and doctors alike may miss the true diagnosis when stress affects the guts. But, equally, a patient’s life may be put at risk if intestinal symptoms, such as a change in bowel habit, diarrhoea, constipation or an alternating pattern of both, are caused by some specific disease and yet are attributed to a psychological cause.

Although people are alert to the possible link between breathlessness and anxiety, few realise that the gastrointestinal tract, the guts, respond to emotions as readily as do the heart, skin, lungs and respiratory system. Often there are more important causes of breathlessness than hyperventilation and the feelings of air hunger that acute anxiety or a panic attack may induce, but patients and doctors alike are aware that a diagnosis other than stress is more likely when a patient is apparently panting and at their last gasp. Sorting out gut problems related to emotional problems rather than as the result of specific disease is perhaps more difficult than when other bodily systems are involved.

Starting at the top and working down, the first symptom that may have a psychological or pathological cause is difficulty in swallowing. People with excessive and comparatively long-term anxiety often get the sensation that something is stuck in their throat, as if they have a small ball lodged in their throat and it is stopping the food going down. The technical term for this condition is globus hystericus. So important is this symptom that it needs full investigation before heavy reassurance, as they say in medical circles, is offered to the patient.

There are a variety of other causes of food seemingly lodging on the way down, including achalasia spasm in the muscles of the gullet (oesophagus). Achalasia affects the lower end of the gullet and causes difficulty in swallowing and sometimes regurgitation of food.

Sometimes the lining of the gullet can become so inflamed, a condition known as oesophagitis, that the swelling causes obstruction. This is often the result of stomach acid flowing back from the stomach into the oesophagus and coming into contact with the gullet lining, which is not resistant to it. The resulting inflammation causes a severe burning pain and the classic acid brash (a bitter-tasting fluid in the gullet). Patients often say food seems to be sticking behind their breastbone. Both achalasia and oesophagitis must be distinguished from oesophageal malignancies. In these cases food is almost always regurgitated, there is obvious weight loss, poor appetite, general malaise, unexplained anaemia and progressive tiredness. Patients may find it easier to swallow liquids than foods.

The obstruction to the throat may also follow pressure on the oesophagus from the outside, for example, an enlarged thyroid, a gland or a blood vessel or from neurological disease. The golden rule in medicine when dealing with a patient who complains of difficulties in swallowing is that however certain the diagnosis may seem from the history, it always needs thorough investigation. The physical causes of upper central abdominal pain such as might be caused by gastritis, duodenitis (inflammation of the duodenum), whether or not associated with ulceration, are well known. Usually the pain from the stomach is made worse by eating, whereas that from the duodenum may be eased by it. Both sorts of pain follow a meal; however, the pain from the stomach tends to come on earlier than that from the duodenum. These pains need distinguishing from gall bladder disease, pancreatic inflammation and a host of other conditions.

The large bowel gives rise to more problems — the most frequent being irritable bowel syndrome — than any other part of the intestinal tract. The number of people with IBS outnumber all other patients in a hospital outpatient clinic. At any one time in the UK 20 per cent of people have IBS diagnosed (the characteristic symptoms are shown in the box below). Patients who have had a change of bowel pattern, or persistently severe symptoms should seek further investigation. The inflammatory bowel conditions — Crohn’s disease and ulcerative colitis and proctitis — are comparatively common and becoming more frequent and patients may present with colorectal symptoms.

SYMPTOMS TO WATCH OUT FOR
BOWEL CANCER:

persistent change in bowel habits, either constipation or diarrhoea, or in structure of stools for more than six weeks (some doctors say three weeks);
rectal bleeding or blood in the stools;
abdominal pain, colic, or tenderness;
unexplained weight loss, anaemia or tiredness;
abdominal lump

IRRITABLE BOWEL SYNDROME:

abdominal pain relieved by defecation;
diarrhoea or constipation;
excessive wind, bloating and abdominal distension;
passing mucus;
sensation of incomplete evacuation