Approach to the Patient with Gastrointestinal Complaints

Psychosocial Factors of Gastrointestinal Disease

Locke's review in Sleisenger and Fordtran's Gastrointestinal and Liver Disease (8th edition) provides an excellent framework of the biopsychosocial approach to the patient with GI complaints. In caring for patients with both acute and chronic GI disorders, family physicians should obtain a patient-centered, nondirected history, using open-ended questions that enable patients to tell the history in their words. Medical and social histories should be integrated so that symptomatic complaints are described in the context of the psychosocial events surrounding the presenting illness, including the setting of symptom onset and exacerbation. Throughout the encounter, the provider's questions should communicate a sincere willingness to address both biologic and psychologic aspects of the illness. Evaluation and treatment of GI symptoms depend on a strong physician-patient therapeutic relationship, allowing the family physician to elicit, evaluate, and communicate the role of potential psychosocial factors in the disease state. Patient reassurance, acknowledgment of patient adaptations to chronic illness, reinforcement of healthy behaviors, and the consideration of psychopharma-cologic medication are paramount (Locke, 2006).

The failure to find a specific structural etiology for a patient's GI symptoms is usually the rule rather than the exception in the ambulatory care setting. Because functional GI disorders may represent an "illness without an evident disease," some providers do not regard these as legitimate, especially within the biopsychosocial model of disease. This phenomenon often leads physicians (and patients to coerce physicians) to pursue unnecessary, costly, and invasive diagnostic tests to find the etiology of a patient's symptoms, rather than focusing directly on symptom management and potential psychological comorbidities. Family physicians must establish clear boundaries with their patients to prevent unnecessary workups and, when indicated, should consider a referral to a mental health professional skilled in the care of patients with functional GI conditions, to assist in symptom management (Locke, 2006).

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