“Food gets stuck in my throat.”

“What’s making me vomit?”

“I’m constipated and bloated.”

“Help! I have diarrhea.”

These are the complaints that gastroenterologists hear on repeat. But as frequent as they are, they’re not always as straightforward or insignificant as they might seem.

Four gastroenterologists talked to Medscape Medical News about the importance of taking common gut complaints seriously — even when patients do not. Thinking beyond the obvious can make a difference in pinpointing a complaint that could turn serious, or already is, or in finding the most effective treatment.

Swallowing Difficulties: ‘No Big Deal’ to Patient

A 70-year-old man mentioned to his primary care physician (PCP) that he had difficulty with some food getting stuck in his throat, primarily two of his favorite foods — chicken and rice. “His PCP was insistent that he come in and see me,” said Rena Yadlapati, MD, professor of gastroenterology at the University of California San Diego (UCSD) and medical director of the UCSD Center for Esophageal Diseases. The patient did so reluctantly, she said, as he wasn’t bothered by it.

He told her it was fine, and that he had no heartburn or acid reflux. Even so, Yadlapati pressed on. “One symptom I never take lightly is dysphagia,” she said. “When the esophagus is functioning normally and the anatomy is intact, a patient should not be experiencing any dysphagia.”

The question she focuses on is: Could there be an esophageal component? If suspected, mechanical and anatomical issues must be ruled out. “I have seen esophageal cancer and severe strictures that are missed or the diagnosis is delayed in a patient who comes in with dysphagia [that’s not properly addressed],” she told Medscape Medical News.

Even if a patient has had a prior endoscopy and was told it was normal, “If you have any concerns, repeat the endoscopy,” Yadlapati said. “Things can be missed, things can progress.” She also stressed the need to follow the quality indicators for upper gastrointestinal endoscopy.

In this case, she did an endoscopy and found a severe peptic stricture. Her patient had erosive esophagitis. “We did a dilation and started him on proton pump inhibitors and talked about lifestyle measures,” she said.

When Yadlapati saw the patient for a recent follow-up, he told her that after being on the medication for some time, he felt better and realized he had had the symptoms she had asked him about.

“We did another dilation at the follow-up and he’s doing fantastic,” she reported.

Just Vomiting, or Rumination Syndrome?

Gastroenterologists know a patient’s definition of vomiting can differ from their own.

“Patients call anything that comes up to their mouth vomiting,” said Prakash Gyawali, MD, professor of medicine in the Division of Gastroenterology, Washington University School of Medicine, St. Louis, and associate editor of the American Journal of Gastroenterology.

However, he said, it’s crucial to differentiate true vomiting — the body expels what’s in the stomach, sending it upward through the esophagus and out of the mouth — from other conditions that patients may call vomiting.

“When stomach contents arrive in the mouth without effort, that’s called regurgitation,” Gyawali said. While regurgitation often happens in patients with gastroesophageal reflux disease, it is also associated with another condition that gastroenterologists need to be aware of, he explained.

The condition, known as rumination syndrome, is described as an underdiagnosed behavioral disorder and is thought to have a prevalence of under 6%. The regurgitation occurs due to increased gastric pressure due to subconscious contraction of the abdominal musculature wall. The contraction reverses the pressure gradient between the esophagus and the stomach.

Patients with this disorder learn how to bring up the stomach contents into the mouth, Gyawali said. They then “may rechew and swallow,” explaining the use of the term “rumination,” as this is similar to the behavior of ruminant animals such as cows.

As an esophageal expert, Gyawali said he sees a patient with rumination syndrome every 2-3 months, but other gastroenterologists may understandably have seen few or no such patients.

It’s important to find out more details from taking a good patient history, he said, as the condition can be difficult to diagnose. Regurgitation happens after meals, and the behavior stops when it’s not pleasurable. Patients are often younger, with a history of psychological issues, Gyawali told Medscape Medical News. 

For a recent patient, the episodes occurred after meals, never in the middle of the night, and never when a significant life stressor was not present. Testing can help determine if reflux is present. In this case, testing showed it was not reflux, he said.

Another indication pointing to possible rumination syndrome is when a patient thought to have reflux is prescribed treatment and doesn’t respond to it.

After testing this recent patient, Gyawali referred her to diaphragmatic breathing training, emphasized the role of the life stressor in triggering the behavior, and prescribed anti-anxiety medication.

“She completely recovered and the episodes went away,” he said.

Sensitive Stomach or Pelvic Floor Dysfunction?

The patient is typically female and middle aged and is frequently referred to a gastroenterologist for irritable bowel syndrome (IBS) and constipation. The patient complains of always having a “sensitive stomach,” with bloating and other issues, said Darren M. Brenner, MD, professor of medicine and surgery at Northwestern University Feinberg School of Medicine, Chicago. 

But often, “what they really have is pelvic floor dysfunction,” said Brenner, who is also the American College of Gastroenterology governor for Illinois. “They can’t coordinate the muscles in their pelvic floor to evacuate,” he explained.

These patients are often referred for evaluation to an academic center, such as his, to get to the root of the issue. Some patients referred to him have been diagnosed with IBS for 30 or 40 years. Once he tests their pelvic floor muscles, the diagnosis becomes different, Brenner said.

“In layman’s terms, they have a door at the bottom that won’t open fully or won’t open at all,” he told Medscape Medical News. The treatment for this dyssynergic defecation is pelvic floor physical therapy and biofeedback to retrain the muscles to work correctly.

Pelvic floor rehabilitation includes individualized programs that can train the muscles to increase the ability to hold and release urine and stool. After a few months of the treatment, “in the hands of a good pelvic floor physical therapist, patients can improve 70-80% of the time,” said Brenner, who has published on the topic and edited a special issue of Gastroenterology Clinics of North America on pelvic floor disorders.

Constipation or Overflow Diarrhea?

When patients complain of diarrhea, consider the possibility that constipation could be present as well, said William Chey, MD, Pollard professor of gastroenterology and nutritional sciences and chief of the Division of Gastroenterology, Michigan Medicine, Ann Arbor, Michigan. He is also president of the American College of Gastroenterology.

Chey is referring to overflow diarrhea, also known as paradoxical diarrhea, which is when there is fecal impaction in the lower part of the digestive tract. Paradoxically, he explained, the treatment for overflow diarrhea is to clean out the stool. A bowel program with laxatives can help the patient to get back to more normal bowel habits.

How does one find out if it’s actually overflow diarrhea? “There are two ways to diagnose this,” Chey told Medscape Medical News. One is to perform a digital rectal exam in the clinic. If there is a large amount of stool, “that’s pretty much of a dead giveaway” that the condition is overflow diarrhea.

Another approach is an abdominal x-ray. Finding a large amount of excess stool burden in the colon, especially the distal colon, is highly indicative of overflow diarrhea, he said. An office-based ultrasound machine is more convenient than an x-ray to look for the excess stool, added Chey, who uses this approach.

Recently, the gastroenterologist cared for an older woman who reported initially having a bowel movement only every 2 or 3 days. Then, after a change in habits, she had a large bowel movement only once a week, with small amounts of liquid stool daily.

She was bothered by the loose stool and occasionally had fecal incontinence, Chey reported.

After finding a large amount of stool in the rectum, he concluded it was overflow diarrhea. “We cleaned her out with two bottles of magnesium citrate, then started her on a bowel regimen.” For her, this involved taking 500-1000 mg of magnesium oxide every day. He also recommended daily walks — as much as the patient could manage — and increasing water intake.

She improved on the regimen. For those patients who prefer natural remedies, he suggests upping their intake of kiwi fruit or prune.

Yadlapati is a consultant for Medtronic, Braintree, and Phathom Pharmaceuticals. Gyawali, Brenner, and Chey reported having no relevant disclosures.