• 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

faeculent

• associated weight loss

• the patient’s medications.

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

infarction.

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

include:

• drugs, such as alcohol, opioids, theophyllines, digoxin,

cytotoxic agents or antidepressants

• pregnancy

• diabetic ketoacidosis

• renal or liver failure

• hypercalcaemia

• Addison’s disease

• raised intracranial pressure (meningitis, brain tumour)

• vestibular disorders (labyrinthitis and Ménière’s disease).

Wind and flatulence

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

to air swallowing (aerophagy) and has no medical significance. Fig. 6.6 Abdominal distension due to ascites.

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.

Bleeding

Haematemesis

Haematemesis is the vomiting of blood.

Ask about:

• Colour: is the vomitus fresh red blood or dark brown,

resembling coffee grounds?

• Onset: was haematemesis preceded by intense retching

or was blood staining apparent in the first vomit?

• History of dyspepsia, peptic ulceration, gastrointestinal

bleeding or liver disease.

• Alcohol, non-steroidal anti-inflammatory drugs (NSAIDs)

and glucocorticoid ingestion.

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.

Ask about:

• onset of diarrhoea: acute, chronic or intermittent

• stool:

• frequency

• volume

• colour

• 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

disturbance

• recent travel and where to

• 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

inflammatory bowel disease

• osmotic, due to malabsorption, drugs (as in laxative

abuse) or motility disorders (autonomic neuropathy,

particularly in diabetes).

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.