Relieving factors Food, antacids, vomiting – Sitting upright –
Severity Mild to moderate Severe Severe Severe
6.3 Non-alimentary causes of abdominal pain
Myocardial infarction Epigastric pain without tenderness
Angor animi (feeling of impending death)
Lateralised pain restricting movement
Tenderness overlying involved vertebra
Cord compression Pain on percussion of thoracic spine
Hyperaesthesia at affected dermatome with
Pleurisy Lateralised pain on coughing
Herpes zoster Hyperaesthesia in dermatomal distribution
Diabetic ketoacidosis Cramp-like pain
Suprapubic and iliac fossa pain, localised
Torsion of testis/ovary Lower abdominal pain
98 • The gastrointestinal system
Patients with dysphagia complain that food or drink sticks when
• onset: recent or longstanding
• nature: intermittent or progressive
• difficulty swallowing solids, liquids or both
• the level the patient feels food sticks at
• any regurgitation or reflux of food or fluid
• any associated pain (odynophagia), heartburn or
Do not confuse dysphagia with early satiety, the inability to
complete a full meal because of premature fullness, or with
globus, which is a feeling of a lump in the throat. Globus does
not interfere with swallowing and is not related to eating.
Neurological dysphagia resulting from bulbar or pseudobulbar
palsy (p. 129) is worse for liquids than solids, and may be
accompanied by choking, spluttering and fluid regurgitating
Neuromuscular dysphagia, or oesophageal dysmotility, presents
in middle age, is worse for solids and may be helped by liquids and
sitting upright. Achalasia, when the lower oesophageal sphincter
fails to relax normally, leads to progressive oesophageal dilatation
above the sphincter. Overflow of secretions and food into the
respiratory tract may then occur, especially at night when the
patient lies down, causing aspiration pneumonia. Oesophageal
dysmotility can cause oesophageal spasm and central chest
pain, which may be confused with cardiac pain.
A pharyngeal pouch may cause food to stick or be regurgitated,
and may lead to recurrent chest infections due to chronic silent
Exacerbating and relieving factors
Pain exacerbated by movement or coughing suggests
inflammation. Patients tend to lie still to avoid exacerbating the
pain. People with colic typically move around or draw their knees
up towards the chest during spasms.
Excruciating pain, poorly relieved by opioid analgesia, suggests
an ischaemic vascular event, such as bowel infarction or ruptured
abdominal aortic aneurysm. Severe pain rapidly eased by potent
analgesia is more typical of acute pancreatitis or peritonitis
secondary to a ruptured viscus.
Features of the pain can help distinguish between possible
The majority of general surgical emergencies are patients with
sudden severe abdominal pain (an ‘acute abdomen’). Patients
may be so occupied by recent and severe symptoms that they
forget important details of the history unless asked directly. Seek
additional information from family or friends if severe pain, shock
or altered consciousness makes it difficult to obtain a history
from the patient. Note any relevant past history, such as acute
perforation in a patient with known diverticular disease. Causes
range from self-limiting to severe life-threatening diseases (Box
6.4). Evaluate patients rapidly, and then resuscitate critically ill
patients immediately before undertaking further assessment
and surgical intervention. Parenteral opioid analgesia to alleviate
severe abdominal pain will help, not hinder, clinical assessment.
In patients with undiagnosed acute abdominal pain, reassess
their clinical state regularly, undertake urgent investigations
and consider surgical intervention before administering repeat
6.4 Typical clinical features in patients with an ‘acute abdomen’
Acute appendicitis Nausea, vomiting, central abdominal pain that later shifts to
Fever, tenderness, guarding or palpable mass in right iliac
fossa, pelvic peritonitis on rectal examination
Vomiting at onset associated with severe acute-onset
abdominal pain, previous history of dyspepsia, ulcer disease,
non-steroidal anti-inflammatory drugs or glucocorticoid therapy
Shallow breathing with minimal abdominal wall movement,
abdominal tenderness and guarding, board-like rigidity,
abdominal distension and absent bowel sounds
Acute pancreatitis Anorexia, nausea, vomiting, constant severe epigastric pain,
previous alcohol abuse/cholelithiasis
Fever, periumbilical or loin bruising, epigastric tenderness,
variable guarding, reduced or absent bowel sounds
Sudden onset of severe, tearing back/loin/abdominal pain,
hypotension and past history of vascular disease and/or high
Shock and hypotension, pulsatile, tender, abdominal
mass, asymmetrical femoral pulses
Anorexia, nausea, vomiting, bloody diarrhoea, constant
abdominal pain, previous history of vascular disease and/or
Atrial fibrillation, heart failure, asymmetrical peripheral
pulses, absent bowel sounds, variable tenderness and
Intestinal obstruction Colicky central abdominal pain, nausea, vomiting and
Surgical scars, hernias, mass, distension, visible
peristalsis, increased bowel sounds
Premenopausal female, delayed or missed menstrual period,
hypotension, unilateral iliac fossa pain, pleuritic shoulder-tip
pain, ‘prune juice’-like vaginal discharge
Suprapubic tenderness, periumbilical bruising, pain and
tenderness on vaginal examination (cervical excitation),
swelling/fullness in fornix on vaginal examination
Sexually active young female, previous history of sexually
transmitted infection, recent gynaecological procedure,
pregnancy or use of intrauterine contraceptive device, irregular
menstruation, dyspareunia, lower or central abdominal pain,
backache, pleuritic right upper quadrant pain (Fitz-Hugh–Curtis
Fever, vaginal discharge, pelvic peritonitis causing
tenderness on rectal examination, right upper quadrant
tenderness (perihepatitis), pain/tenderness on vaginal
examination (cervical excitation), swelling/fullness in fornix
It may indicate anxiety but sometimes occurs in an attempt to
relieve abdominal pain or discomfort, and accompanies GORD.
Normally, 200–2000 mL of flatus is passed each day. Flatus
is a mixture of gases derived from swallowed air and from
colonic bacterial fermentation of poorly absorbed carbohydrates.
Excessive flatus occurs particularly in lactase deficiency and
Borborygmi result from movement of fluid and gas along the
bowel. Loud borborygmi, particularly if associated with colicky
discomfort, suggest small bowel obstruction or dysmotility.
Abdominal girth slowly increasing over months or years is usually
due to obesity but in a patient with weight loss it suggests
intra-abdominal disease. The most common causes of abdominal
• flatus in pseudo-obstruction or bowel obstruction
• faeces in subacute obstruction or constipation
• fluid in ascites (accumulation of fluid in the peritoneal
cavity; Fig. 6.6), tumours (especially ovarian) or distended
• functional bloating (fluctuating abdominal distension that
develops during the day and resolves overnight, usually
occurring in irritable bowel syndrome).
Clarify what patients mean by diarrhoea. They may complain of
frequent stools or of a change in consistency of the stools. Normal
frequency ranges from three bowel movements daily to once
every 3 days. Diarrhoea is the frequent passage of loose stools.
Steatorrhoea is diarrhoea associated with fat malabsorption. The
stools are greasy, pale and bulky, and they float, making them
‘Mechanical’ dysphagia is often due to oesophageal stricture
but can be caused by external compression. With weight loss,
a short history and no reflux symptoms, suspect oesophageal
cancer. Longstanding dysphagia without weight loss but
accompanied by heartburn is more likely to be due to benign
peptic stricture. Record the site at which the patient feels the
food sticking; this is not a reliable guide to the site of oesophageal
Nausea is the sensation of feeling sick. Vomiting is the expulsion
of gastric contents via the mouth. Both are associated with
pallor, sweating and hyperventilation.
• relation to meals and timing, such as early morning or late
• associated symptoms, such as dyspepsia and abdominal
pain, and whether they are relieved by vomiting
• whether the vomit is bile-stained (green), blood-stained or
Nausea and vomiting, particularly with abdominal pain or
discomfort, suggest upper gastrointestinal disorders. Dyspepsia
causes nausea without vomiting. Peptic ulcers seldom cause
painless vomiting unless they are complicated by pyloric stenosis,
which causes projectile vomiting of large volumes of gastric
content that is not bile-stained. Obstruction distal to the pylorus
produces bile-stained vomit. Severe vomiting without significant
pain suggests gastric outlet or proximal small bowel obstruction.
Faeculent vomiting of small bowel contents (not faeces) is a late
feature of distal small bowel or colonic obstruction. In peritonitis,
the vomitus is usually small in volume but persistent. The more
distal the level of intestinal obstruction, the more marked the
accompanying abdominal distension and colic.
Vomiting is common in gastroenteritis, cholecystitis, pancreatitis
and hepatitis. It is typically preceded by nausea but in raised
intracranial pressure may occur without warning. Severe pain
may precipitate vomiting, as in renal or biliary colic or myocardial
Anorexia nervosa and bulimia are eating disorders characterised
by undisclosed, self-induced vomiting. In bulimia, weight is
maintained or increased, unlike in anorexia nervosa, where
profound weight loss is common.
Other non-gastrointestinal causes of nausea and vomiting
• drugs, such as alcohol, opioids, theophyllines, digoxin,
cytotoxic agents or antidepressants
• raised intracranial pressure (meningitis, brain tumour)
• vestibular disorders (labyrinthitis and Ménière’s disease).
Belching, excessive or offensive flatus, abdominal distension and
borborygmi (audible bowel sounds) are often called ‘wind’ or
flatulence. Clarify exactly what the patient means. Belching is due
100 • The gastrointestinal system
hypercalcaemia, drugs (opiates, iron) and immobility (Parkinson’s
disease, stroke). Absolute constipation (no flatus or bowel
movements) suggests intestinal obstruction and is usually
associated with pain, vomiting and distension. Tenesmus suggests
rectal inflammation or tumour. Faecal impaction can occasionally
present as overflow diarrhoea.
Haematemesis is the vomiting of blood.
• Colour: is the vomitus fresh red blood or dark brown,
• Onset: was haematemesis preceded by intense retching
or was blood staining apparent in the first vomit?
• History of dyspepsia, peptic ulceration, gastrointestinal
• Alcohol, non-steroidal anti-inflammatory drugs (NSAIDs)
If the source of bleeding is above the gastro-oesophageal
sphincter, as with oesophageal varices, fresh blood may well
up in the mouth, as well as being actively vomited. With a lower
oesophageal mucosal tear due to the trauma of forceful retching
(Mallory–Weiss syndrome), fresh blood appears only after the
patient has vomited forcefully several times.
• onset of diarrhoea: acute, chronic or intermittent
• consistency: watery, unformed or semisolid
• contents: red blood, mucus or pus
• associated features: urgency, faecal incontinence or
tenesmus (the sensation of needing to defecate, although
the rectum is empty), abdominal pain, vomiting, sleep
• recent medication, in particular any antibiotics.
High-volume diarrhoea (>1 L per day) occurs when stool water
content is increased (the principal site of physiological water
absorption being the colon) and may be:
• secretory, due to intestinal inflammation, as in infection or
• osmotic, due to malabsorption, drugs (as in laxative
abuse) or motility disorders (autonomic neuropathy,
If the patient fasts, osmotic diarrhoea stops but secretory
diarrhoea persists. The most common cause of acute diarrhoea
is infective gastroenteritis due to norovirus, Salmonella species
or Clostridium difficile. Infective diarrhoea can become chronic
(>4 weeks) in cases of parasitic infestations (such as giardiasis
(Giardia lamblia), amoebiasis or cryptosporidiosis). Steatorrhoea is
common in coeliac disease, chronic pancreatitis and pancreatic
insufficiency due to cystic fibrosis. Bloody diarrhoea may be
caused by inflammatory bowel disease, colonic ischaemia or
infective gastroenteritis. Change in the bowel habit towards
diarrhoea can be a manifestation of colon cancer, in particular
cancer of the right side of the colon and in patients over 50 years.
Thyrotoxicosis is often accompanied by secretory diarrhoea or
Low-volume diarrhoea is associated with irritable bowel
syndrome. Abdominal pain, bloating, dyspepsia and non-alimentary
symptoms commonly accompany irritable bowel symptoms.
Criteria have been developed to define irritable bowel syndrome
more precisely, taking account of the duration of symptoms, the
presence of abdominal pain and its relationship to defecation,
and the frequency and consistency of stools (see Rome IV criteria
for irritable bowel syndrome).
Clarify what the patient means by constipation. Use the Bristol
stool form scale (Fig. 6.7) to describe the stools. Constipation
is the infrequent passage of hard stools.
• onset: lifelong or of recent onset
• stool frequency: how often the patient moves their bowels
each week and how much time is spent straining at stool
• shape of the stool: for example, pellet-like
• associated symptoms, such as abdominal pain, anal pain
on defecation or rectal bleeding
• drugs that may cause constipation.
Constipation may be due to lack of dietary fibre, impaired
colonic motility, mechanical intestinal obstruction, impaired
rectal sensation or anorectal dysfunction impairing the process
of defecation. Constipation is common in irritable bowel syndrome.
Other important causes include colorectal cancer, hypothyroidism,
Formerly Reader in Medicine at the University of Bristol.
Fig. 6.7 Bristol stool form scale. Reproduced with kind permission of
Dr KW Heaton, formerly Reader in Medicine at the University of Bristol.
©2000, Norgine group of companies.
colorectal cancer or colonic polyps, inflammatory bowel disease,
ischaemic colitis and colonic angioectasias.
Jaundice is a yellowish discoloration of the skin, sclerae (Fig. 6.8)
and mucous membranes caused by hyperbilirubinaemia (Box 6.6).
There is no absolute level at which jaundice is clinically detected
but, in good light, most clinicians will recognise jaundice when
bilirubin levels exceed 50 µmol/L (2.92 mg/dL).
• associated symptoms: abdominal pain, fever, weight loss,
• colour of stools (normal or pale) and urine (normal or dark)
• travel history and immunisations
• use of illicit or intravenous drugs
Unconjugated bilirubin is insoluble and binds to plasma albumin;
it is therefore not filtered by the renal glomeruli. In jaundice from
unconjugated hyperbilirubinaemia, the urine is a normal colour
(acholuric jaundice; Box 6.7).
Bilirubin is conjugated to form bilirubin diglucuronide in the
liver and excreted in bile, producing its characteristic green
colour. In conjugated hyperbilirubinaemia, the urine is dark brown
due to the presence of bilirubin diglucuronide. In the colon,
conjugated bilirubin is metabolised by bacteria to stercobilinogen
and stercobilin, which contribute to the brown colour of stool.
Stercobilinogen is absorbed from the bowel and excreted in the
urine as urobilinogen, a colourless, water-soluble compound.
Melaena is the passage of tarry, shiny black stools with a
characteristic odour and results from upper gastrointestinal
bleeding. Distinguish this from the matt black stools associated
with oral iron or bismuth therapy.
Peptic ulceration (gastric or duodenal) is the most common
cause of upper gastrointestinal bleeding and can manifest with
melaena, haematemesis or both. Excessive alcohol ingestion
may cause haematemesis from erosive gastritis, Mallory–Weiss
tear or bleeding oesophagogastric varices in cirrhotic patients.
Oesophageal or gastric cancer and gastric angioectasias (Dieulafoy
lesion) are rare causes of upper gastrointestinal bleeding.
The Rockall and Blatchford scores are used to assess the
risk in gastrointestinal bleeding (Box 6.5). A profound upper
gastrointestinal bleed may lead to the passage of purple stool
Establish whether the blood is mixed with stool, coats the surface
of otherwise normal stool or is seen on the toilet paper or in the
pan. Fresh rectal bleeding (haematochezia) usually indicates a
disorder in the anal canal, rectum or colon. During severe upper
gastrointestinal bleeding, however, blood may pass through the
intestine unaltered, causing fresh rectal bleeding. Common causes
of rectal bleeding include haemorrhoids, anal fissures (blood on
the toilet paper or in the pan), complicated diverticular disease,
6.5 Prediction of the risk of mortality in patients with upper
gastrointestinal bleeding: Rockall score
Pulse >100 beats per minute and systolic
Systolic blood pressure <100 mmHg 2
Heart failure, ischaemic heart disease or
Renal failure or disseminated malignancy 3
Mallory–Weiss tear and no visible
Upper gastrointestinal malignancy 2
Major stigmata of recent haemorrhage
Visible bleeding vessel/adherent clot 2
Pre-endoscopy (maximum score = 7) Score 4 = 14% mortality
Post-endoscopy (maximum score = 11) Score 8+ = 25%
Reproduced from Rockall TA, Logan RF, Devlin HB, et al. Risk assessment after
acute upper gastrointestinal haemorrhage. Journal of the British Society of
Gastroenterology 1996; 38(3):316, with permission from BMJ Publishing
Fig. 6.8 Yellow sclera of jaundice.
Increased bilirubin production
• Haemolysis (unconjugated hyperbilirubinaemia)
102 • The gastrointestinal system
• precipitating/exacerbating factors, such as straining due to
chronic constipation, chronic cough, heavy manual labour
and relationship with micturition
• timing: when the symptoms are worse.
Hernias are common causes of groin lumps and frequently
present with dull, dragging discomfort (rather than acute pain),
which is often exacerbated by straining and after long periods
of standing or activity. Patients can often manually reduce the
hernia by applying gentle pressure over the swelling or by lying
flat. Other causes of groin swellings include lymph nodes, skin
and subcutaneous lumps and, less commonly, saphena varix
(a varicosity of the long saphenous vein), hydrocoele of the
spermatic cord, undescended testis, femoral aneurysm and psoas
History of a similar problem may suggest the diagnosis: for
example, pancreatitis, bleeding peptic ulcer or inflammatory bowel
disease. Coexisting peripheral vascular disease, hypertension,
heart failure or atrial fibrillation may suggest aortic aneurysm or
mesenteric ischaemia as the cause of acute abdominal pain.
Primary biliary cirrhosis and autoimmune hepatitis are associated
with thyroid disease, and non-alcoholic fatty liver disease (NAFLD)
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