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CHAPTER12 Gastrointestinalmedicine
Assessment ofabdominalpain
0 Signs may be unclear in elderly patients, children, or those on steroids.
History Consider:
• Site of pain— Figure 12.1
• Onset:how long? How did it start? Change over time?
• Character of pain:colicky pain comes and goes in waves— results from
GI obstruction, renal/ biliary colic, gastroenteritis, or IBS
• Radiation
• Associated symptoms, e.g. nausea, vomiting, diarrhoea
• Timing/ pattern, e.g. constant, colicky, relationship to food
• Exacerbating/ relieving factors— including previous treatments tried
• Severity
Examination
• Temperature, pulse, BP, respiratory rate
• Anaemia or jaundice?
• Abdomen— site of pain (Figure 12.1); guarding/ rebound tenderness?
• Rectal/ vaginal examination as needed
• Consider urine dipstick/ nger prick blood glucose testing as needed
Management Treat the cause (Table 12.1).
• If acute or subacute onset severe pain, admit as a surgical emergency
to hospital.
Table12.1 Dierential diagnosis ofabdominal pain
Renal/ urological
Renal colic
UTI
Pyelonephritis
Urinary retention/
hydronephrosis
Torsion of the testis
Gynaecological
Ectopic pregnancy
Dysmenorrhoea
Endometriosis
Pelvic inammatory
disease
Ovarian torsion
Ovarian cyst— bleed/
rupture
Gynaecological
malignancy
Gastrointestinal
Surgical
Perforated bowel
Bowel obstruction
Intussusception
Strangulated hernia
Volvulus
Appendicitis
Meckel’s diverticulum
Gallbladder disease
Pancreatitis
GI malignancy
Henoch Schönlein purpura
Medical
Gastritis
Peptic ulcer
Gastroenteritis
Crohn’s/ UC
IBS
Constipation
Diverticular disease
Liver disease
Other intra- abdominal
Sickle cell crisis
Ruptured spleen
Leaking/ ruptured AAA
Mesenteric ischaemia
Mesenteric adenitis
Subphrenic abscess
Metabolic
DM— ketoacidosis
Porphyria
Addison’s disease
Lead poisoning
Other extra- abdominal
Shingles/ post- herpetic
neuralgia
Spinal arthritis
Muscular pain
MI
CCF
Pneumonia
Epigastric pain
a
Right iliac
fossa pain
• Caecum
• Appendix
• Right ovary
• Right Fallopian tube
• Ureter
• Rectum
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ASSESSMENT OFABDOMINALPAIN
Right upper
quadrant pain
• Liver
• Gallbladder
• Duodenum
• Right lung
Right loin pain
• Right kidney
• Colon
• Ureter
• Musculoskeletal
Figure12.1 Location of pain and organs likely to be involved
• Oesophagus
• Stomach
• Duodenum
• Heart
Suprapubic pain
• Bladder
• Uterus
Left upper
quadrant pain
• Stomach
• Spleen
• Left lung
Left loin pain
• Left kidney
• Colon
• Ureter
• Abdominal aort
• Musculoskeletal
Central pain
• Small bowel
• Appendix
• Meckel’s
diverticulum
Left iliac
fossa pain
• Colon
• Left ovary
• Left Fallopian tube
• Ureter
Pelvic pain E p. 690
Anal/ perianal pain Treat the cause. Consider:
• Anal ssure • Pilonidal sinus
• Haemorrhoids/ perianal
haematoma (thrombosed pile)
• Skin infection (e.g. hidradenitis
suppurativa)
• Perianal abscess • Functional pain (proctalgia fugax)
• Anal/ perianal stula • Rectal/ anal carcinoma
Tenesmus Sensation of incomplete rectal emptying following
defecation— as if something has been left behind which cannot be passed.
Common in irritable bowel syndrome. Can be also be caused by proctitis/
inammatory bowel disease and tumour.
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Abdominal migraine or periodic syndrome Seen
in children. Presents as stereotyped attacks in which nausea,
vomiting, and headache accompany abdominal pain. Treat as for
migraine. Some of these children develop classical migraine later.
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CHAPTER12 Gastrointestinalmedicine
Vomiting anddiarrhoea
Most episodes of acute vomiting and diarrhoea are due to viral infection,
short- lived (2– 5d) and self- limiting.
Nausea Unpleasant symptom. The patient feels as if he/ she might vomit.
Most conditions which cause vomiting can also cause nausea.
Vomiting Common symptom. Causes— Table 12.2.
History
• Duration
• Ability to retain food and uids/ relationship to eating
• Nature of vomitus, e.g. presence of blood or ‘coee grounds’; bilious
• Sources of infection:food exposure (e.g. reheated rice, uncooked
chicken); foreign travel; any contacts with similar symptoms?
• Other associated symptoms, e.g. fever, abdominal pain, diarrhoea
• Other illnesses, e.g. DM, Ménière’s disease, migraine, cancer
• Medication, e.g. opioids, chemotherapy
Examination
• Assess hydration status— BP, pulse rate— dry mouth, d skin turgor,
sunken eyes, or sunken fontanelle (babies) are all late signs
• Abdomen— masses, distention, tenderness, bowel sounds
• For children— look for other sources of infection e.g. ENT, chest, UTI
Slimy stool Caused by overproduction of mucus in the large bowel.
Almost always associated with colonic disease/ irritable bowel syndrome.
Investigate unless all other features are typical of IBS and age is <40y.
Diarrhoea Establish what the patient means by diarrhoea. Diarrhoea is
the abnormal passage of loose or liquid stools. Causes— Table 12.2.
History
• Duration— termed ‘chronic’ if persists >4wk
• Nature of the diarrhoea— colour, consistency, blood/ mucus
• Contact with anyone else with similar symptoms?
• Occupation and travel history
• Associated symptoms, e.g. fever, abdominal pain, vomiting, weight d
• Association with other factors (e.g. food intolerance, stress)
• Past medical history— surgery (especially ileal resection or
cholecystectomy); pancreatic disease; systemic disease (e.g. DM,
thyrotoxicosis)
• Family history— inammatory bowel or coeliac disease; bowel cancer
• Alcohol consumption— high intake is associated with diarrhoea
• Medication e.g. antibiotics, regular medications (4% chronic diarrhoea)
Examination
• Assess hydration status— BP, pulse rate— dry mouth, d skin turgor,
sunken eyes, or sunken fontanelle (babies) are all late signs
• Abdomen— masses, distention, tenderness, bowel sounds, stool
Investigation Send a stool sample for M,C&S if any of the following:
• Fever
• Blood in stool
• Food worker
• Recent return from a
tropical climate
• Immunocompromise
• Resident in an
institution
• Persists >7d
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VOMITING ANDDIARRHOEA
Table12.2 Causes ofvomiting and diarrhoea
Vomiting Diarrhoea
Physiological:e.g. posseting in babies
Travel/ motion sickness
GI infection:e.g. viral gastroenteritis,
food poisoning
Other infection (particularly
children):tonsillitis, otitis media
Other GI causes:GI obstruction, pyloric
stenosis, cow’s milk protein allergy,
‘acute abdomen’
CNS causes:raised intracranial pressure,
head injury, migraine, vertigo
Metabolic causes:pregnancy, uraemia,
ketoacidosis
Psychiatric causes:anorexia, bulimia
Malignancy
Drugs and toxins:e.g. alcohol, opioids,
cytotoxic agents
Acute diarrhoea
• Dietary indiscretion
• Infection, e.g. food poisoning,
traveller’s diarrhoea
• Constipation with overow
• Pseudomembranous colitis— recent
history of oral antibiotics
• Onset of inammatory bowel
disease or
• Other chronic diarrhoea
Chronic diarrhoea
Table12.12, E p. 379
Management ofacute diarrhoea and/ orvomiting
• Treat any identied cause
• Rehydration— encourage clear uid intake (small amounts frequently) ±
rehydration salts (use a commercial preparation e.g. Dioralyte®)
• Food— stick to a bland diet avoiding dairy products until symptoms
have settled. Babies who are breastfed or have not been weaned should
continue their normal milk
• If dehydrated and unable to replace uids, e.g. diarrhoea with
concomitant vomiting, or child/ elderly person refusing to drink— admit
• Never give children antidiarrhoeal agents.
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0 If no cause is found and diarrhoea lasts >4wk, or any atypical features
consider referral for urgent investigation— E p. 378
Haematemesis E p. 1061
Faecal incontinence E p. 380
Gastroenteritis E p. 348
Factitious diarrhoea E p. 379
Chronic diarrhoea and malabsorption E p. 378
Melaena or rectal bleeding E p. 1061
• Some children may become cow’s milk intolerant after a
bout of gastroenteritis— E p. 867
• Think of haemolytic uraemic syndrome in any child with
diarrhoea who passes blood in the stool
Further information
NICE (2009) Diarrhoea and vomiting in children under 5. M www.nice.
org.uk/ Guidance/ CG84
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CHAPTER12 Gastrointestinalmedicine
Gastroenteritis and foodpoisoning
Ingestion of viruses, bacteria, or their toxins commonly causes diarrhoea
and/ or vomiting. 0 Suspected food poisoning is a notiable disease.
Prevention Handwashing after using the toilet; longer cooking and
rewarming times; prompt consumption of food.
Presentation Common causes— Table 12.3.
• History Severity and duration of symptoms, food eaten and water
drunk, time relationship between ingestion and symptoms, other
aected contacts, recent foreign travel
• Examination Usually normal. Dehydration may prompt admission
Investigation and management See vomiting and diarrhoea—
Ep.346. Advise uid replacement. Only give antibiotics if recommended
following stool culture (except Giardia diarrhoea— E p. 625).
Campylobacter Most common bacterial cause of infectious diarrhoea
in the UK. 2 species (C.jejuni and C. coli) are responsible for most cases.
Symptoms occur 2– 5d after ingestion of infected food (usually milk or
poultry). Malaise followed by abdominal pain and diarrhoea— often bloody.
Rarely associated with arthritis. Usually clears spontaneously. If needed,
treatment is with erythromycin or ciprooxacin.
Salmonella Common cause of infectious diarrhoea. Usually ingested in
infected meat, poultry, or eggs. Symptoms: vomiting, diarrhoea, abdominal
pain, and fever— develop from 12h– 2d after ingestion. Rarely associated
with arthritis 2– 3wk after acute infection. In <1% a carrier state develops.
Only use antibiotics on microbiologist advice.
Escherichia coli Many dierent strains of E.coli cause diarrhoea via a
variety of mechanisms. In most cases, treatment is supportive with uid
replacement. Rarely, for enterohaemorrhagic strains, antibiotics may be recommended, but use is controversial as antibiotic treatment has been linked
with haemolytic uraemic syndrome.
Cryptosporidium Protozoan causing diarrhoeal disease. Infections
are usually spread in water. Responsible for 75% of all gastroenteritis in
both industrialized and developing countries. Presents with profuse
watery diarrhoea, abdominal cramp ± nausea, anorexia, fever, and malaise. Treatment is supportive. Usually symptoms last 1– 2wk (rarely >1mo).
Immunocompromised patients develop profuse intractable diarrhoea which
is dicult to clear and may continue intermittently for life.
Norovirus (‘winter vomiting virus’) Most common cause of in-
fectious gastroenteritis in the UK— particularly in communal settings, e.g.
schools, hospitals. Illness is generally mild and lasts 2– 3d. There are no
long- term eects. Infections can occur at any age because immunity is not
long-lasting. Scrupulous hygiene is needed to contain outbreaks.
Further information
Health Protection Infectious diseases:gastrointestinal infections. M www.
gov.uk/ topic/ health- protection/ infectious- diseases
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GASTROENTERITIS AND FOODPOISONING
Table12.3 Common causes ofgastroenteritis inthe UK
Organism/ source Incubation Symptoms Food
B. cereus 1– 5h Rice
Campylobacter 48h– 5d Blood in stool Milk, poultry
C. botulinum 12– 36h Paralysis Canned food
C. perfringens 6– 24h Meat
E. coli 12– 72h Blood in stool Food, water
Salmonella spp. 12– 48h Meat, eggs,
ND
Shigella
Staph. aureus 1– 6h d BP Meat
V. para-haemolyticus 12– 24h Fish
Y. enterocolitica 24– 36h Milk, water
Giardia lamblia 1– 4wk Water
Entamoeba histolytica 1– 4wk Blood in stool Food, water
Cryptosporidium 4– 12d Water
Listeria Flu- like illness,
Norovirus 24– 48h Malaise Food, water
Rotavirus 1– 7d Malaise Food, water
Mushrooms 15min– 24h Fits, coma,
Scombrotoxin 10– 60min Flushes,
Heavy metals, e.g. zinc 5min– 2h
D=diarrhoea; V=vomiting; P=abdominal pain; F=fever; O=other.
48– 72h Blood in stool Any food
D V P F O
pneumonia,
miscarriage
renal/ liver
failure
erythema
poultry
Milk products,
pâtés, raw
vegetables
Fish
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Rotavirus Most common cause of gastroenteritis in children.
Most are immune by 5y. Presents with malaise, abdominal pain,
diarrhoea, and vomiting. Common cause of hospital admission.
Treatment is supportive. Babies in the UK are oered rotavirus
vaccination within the childhood immunization programme (E p. 619).
0 Some children may become cow’s milk intolerant after a bout of
gastroenteritis— E p. 867.
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CHAPTER12 Gastrointestinalmedicine
Constipation
3million GP consultations/ y in the UK result from constipation. Dierentiate
normal stools a few days apart (normal, needs no treatment) and infrequent
hard stools (suggests constipation).
Denition 2 or more of the following for ≥3mo:
• Straining at defecation ≤25% of the time
• Asensation of incomplete evacuation ≥25% of the time
• ≤2 bowel movements/ wk
• Lumpy and/ or hard stools ≥25% of the time
0 Most patients consulting in general practice do not meet these criteria.
Children withconstipation E p. 866
Young patients <40y withlone constipation : 89:1. Establish
symptoms— constipation is usually longstanding in this group. Include drug
and diet history. Ask about health beliefs— 80% believe their bowels should
open daily. Explore concerns about underlying disease. If long- standing ask
why the patient is consulting now. Examine the abdomen. Investigate if
symptoms/ signs suggestive of organic disease (Table 12.4).
Management Treat organic causes. Otherwise:
• Give lifestyle advice— i uid intake to ≤2L/ d (8– 10 cups); avoid
alcohol; i exercise if possible; add bre to diet (i fruit/ vegetables, eat
wholegrain foods, add bran/ oats); open bowel when needed
• If lifestyle advice fails and symptoms cause distress, start a bulk- forming
laxative, e.g. ispaghula husk (avoid in opioid constipation). If this fails, try
an osmotic laxative, e.g. a macrogol or MgOH 15mL bd
• If an osmotic laxative fails, try a short course of stimulant laxative,
e.g. senna 1– 2 tablets at 5p.m. either alone or in combination with an
osmotic laxative. Long- term use of some stimulant laxatives is reported
to cause cathartic atonic colon. Although this is unlikely in young, t
patients only use short courses or use intermittently, e.g. twice weekly
• If still constipated, specialist referral is warranted
Table12.4 Organic causes ofconstipation
Colonic disease • Carcinoma
Anorectal disease • Anterior mucosal prolapse
Pelvic disease • Ovarian tumour
Endocrine/ metabolic
disorders
Drugs • Opioids
Other • Pregnancy
• Diverticular disease
• Crohn’s disease
• Distal proctitis
• Uterine tumour
• Hypercalcaemia
• Hypothyroidism
• Antacids containing calcium
or aluminium
• Antidepressants
• Iron
• Immobility
• Stricture
• Intussusception
• Volvulus
• Anal ssure
• Perianal abscess
• Endometriosis
• DM with autonomic
neuropathy
• Antiparkinsonian drugs
• Anticholinergics
• Anticonvulsants
• Antihistamines
• Calcium antagonists
• Poor uid intake
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CONSTIPATION
Irritable bowel syndrome (IBS) withconstipation 20% develop
symptoms of IBS in their lifetime (E p. 388). Constipation is the predominant symptom in 30% but other symptoms are usually present. Establish
symptoms. Examine the abdomen. Investigation includes FBC, CRP, and
TTG to exclude organic causes (E p. 388).
Management If <40y, examination and investigations are normal, and fulls
IBS criteria (E p. 388), manage as for young patients with lone constipation
but avoid osmotic laxatives as they make bloating worse.
Constipation inthe over40s Any sustained change in bowel habit for
>6wk should be taken seriously and investigated if appropriate. Establish
symptoms and onset. Specically ask about tenesmus, blood in stool, abdominal pain, and diarrhoea. Check current medication. Examine the abdomen for masses and hepatomegaly. Rectal examination is essential to
exclude low rectal or anal carcinoma and detect faecal impaction.
Management
• Check FBC, ESR, renal function, LFTs, TFTs, and serum glucose
• Image the lower bowel by colonoscopy or CT colography if new
symptoms that persist >6wk
• Treat any reversible, underlying organic cause— Table 12.4
• Give lifestyle advice (see management of constipation <40y, E p. 350)
• Treat symptomatically if no cause is found/ cause is untreatable
• Laxatives— consider a bulk- forming laxative (e.g. ispaghula) or osmotic
(e.g. magnesium hydroxide, macrogol,) ± a stimulant laxative (e.g.
senna). Titrate dose to response
• Long- term use of stimulant laxatives including co- danthrusate is
acceptable in the very elderly. Otherwise use prn or intermittently
• If oral laxatives are ineective, consider adding rectal measures. If soft
stool, try bisacodyl suppositories (0 must come into direct contact
with rectum); if hard stools, try glycerol suppositories (act in 1– 6h)
• If still not cleared/ faecal impaction— refer to the district nurse for
lubricant ± high phosphate (stimulant) enema (acts in ~2 min)
• Once constipation has been cleared, leave the patient with clear
instructions about what to do if symptoms recur
H High- risk patients e.g. patients on opioids; those who are immobile
or have medical conditions which predispose them to constipation. Preempt constipation by putting high- risk patients on regular aperients.
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Occult presentations ofconstipation are common in the
elderly and include:
• Confusion
• Urinary retention
• Abdominal pain
• Overow diarrhoea
• Loss of appetite and nausea
Further information
NICE CKS (2017) Constipation M https:// cks.nice.org.uk/ constipation
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CHAPTER12 Gastrointestinalmedicine
Other abdominal symptoms andsigns
Dyspepsia E p. 354
Abdominal distention Consider abdominal/ pelvic masses and:
• Fluid— ascites or full
bladder
• Fat
Abdominal masses Distinguished from pelvic masses by the ability
to get beneath them. Causes: malignancy— any intra- abdominal organ or
kidney; stool; abdominal aortic aneurysm; hepato- and/ or splenomegaly;
appendix mass/ abscess; Crohn’s mass; lymph nodes or TB mass. 0 A
hernia may present as a mass in abdominal wall/ groin lump— E p. 364.
Pelvic masses Causes:fetus; full bladder; broids; gynaecological malig-
nancy; bladder cancer.
Splenomegaly Causes:
• Haematological Lymphoma, leukaemia, myeloproliferative disorders,
sickle cell disease (children usually), thalassaemia
• Inammatory RA or Sjögren’s syndrome, sarcoid, amyloid
• Infection Glandular fever, malaria, SBE, TB, leishmaniasis
Hepatomegaly Causes:
• Apparent Riedel’s lobe, low- lying diaphragm
• Tumours Secondary (most common), primary
• Venous congestion Heart failure, hepatic vein occlusion
• Haematological Leukaemia, lymphoma, myeloproliferative disorders,
sickle cell disease
• Biliary obstruction Particularly extrahepatic
• Inammation Hepatitis, abscess, schistosomiasis
• Metabolic Fatty liver, amyloid, glycogen storage disease
• Cysts Polycystic liver, hydatid
Ascites Free uid in the peritoneal cavity. Signs: abdominal distention,
shifting dullness to percussion, uid thrill. Causes:malignancy— any intraabdominal organ, ovary, or kidney; hypoproteinaemia, e.g. nephrotic syndrome; right heart failure; portal hypertension.
Fistula Abnormal communication between 1 organ and another— usually
due to cancer, or complication of surgery. Presentation— Table 12.5. Refer
urgently if suspected.
• Faeces
• Flatus— intestinal
obstruction; air swallowing
• Fetus
• Food, e.g.
malabsorption
Table12.5 Presentation ofstula
Connection Presentation
Bowel l skin Faecal discharge through surgical wound
Bladder/ ureters l skin Clear, watery discharge which smells of urine
Bowel l vagina Feculent material in vagina
Bladder l vagina Leakage of urine per vaginum
Bowel l bladder Air or feculent material in urine; recurrent UTI
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OTHER ABDOMINAL SYMPTOMS ANDSIGNS
• Referral forsuspected GI cancer
Urgent referral (to be seen in<2wk)
To a team specializing in upper GI cancer if:
• Upper abdominal mass consistent with stomach/ pancreatic cancer
• Aged ≥40y + jaundice
To a team specializing in colorectal cancer if:
• Any age + anal ulceration
• Any age + anal, rectal, or abdominal mass
• Any age + rectal bleeding + unexplained abdominal pain, change in
bowel habit, weight loss, or iron deciency anaemia
• Aged ≥40y + unexplained weight loss + abdominal pain, or
• Aged ≥50y + unexplained rectal bleeding, or
• Aged ≥60y + iron- deciency anaemia or persistent change in bowel
habit or faecal occult blood +ve
For upper GI endoscopy if:
• Dysphagia
• Aged ≥55y + weight loss + upper abdominal pain, reux, and/ or
dyspepsia
For direct access CT (or USS if CT not available) if:≥60y + weight loss
AND ≥1 of:
• Diarrhoea • Nausea/ vomiting
• Back pain • Constipation
• Abdominal pain • New- onset diabetes
For direct access USS if:upper abdominal mass consistent with enlarged
liver or gallbladder.
Non- urgentreferral
For upper GI endoscopy if:
• Haematemesis, or
• Aged ≥55y with:
• Treatment- resistant dyspepsia, or
• Upper abdominal pain and d Hb, or
• i platelet count + nausea/ vomiting, weight d, reux, dyspepsia,
and/ or upper abdominal pain, or
• Nausea/ vomiting + weight loss, reux, dyspepsia, and/ or upper
abdominal pain
0 H. pylori status should not aect the decision to refer for suspected
cancer. Consider checking a FBC to exclude iron deciency anaemia in all
patients presenting with new- onset dyspepsia.
N
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Further information
NICE (2015, updated 2017)Suspected cancer:recognition and referral. M
www.nice.org.uk/ guidance/ ng12
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