Onset Gradual Rapidly increasing Sudden Rapidly increasing

Character Gnawing Constant Constant Constant

Radiation Into back Below right scapula Into back Into genitalia and inner thigh

Associated symptoms Non-specific Non-specific Non-specific Non-specific

Timing

Frequency/periodicity Remission for weeks/months Attacks can be enumerated Attacks can be enumerated Usually a discrete episode

Special times Nocturnal and especially

when hungry

Unpredictable After heavy drinking Following periods of

dehydration

Duration 1

2 –2 hours 4–24 hours >24 hours 4–24 hours

Exacerbating factors Stress, spicy foods, alcohol,

non-steroidal antiinflammatory drugs

Eating – unable to eat

during bouts

Alcohol

Eating – unable to eat

during bouts

–

Relieving factors Food, antacids, vomiting – Sitting upright –

Severity Mild to moderate Severe Severe Severe

6.3 Non-alimentary causes of abdominal pain

Disorder Clinical features

Myocardial infarction Epigastric pain without tenderness

Angor animi (feeling of impending death)

Hypotension

Cardiac arrhythmias

Dissecting aortic

aneurysm

Tearing interscapular pain

Angor animi

Hypotension

Asymmetry of femoral pulses

Acute vertebral

collapse

Lateralised pain restricting movement

Tenderness overlying involved vertebra

Cord compression Pain on percussion of thoracic spine

Hyperaesthesia at affected dermatome with

sensory loss below

Spinal cord signs

Pleurisy Lateralised pain on coughing

Chest signs, e.g. pleural rub

Herpes zoster Hyperaesthesia in dermatomal distribution

Vesicular eruption

Diabetic ketoacidosis Cramp-like pain

Vomiting

Air hunger

Tachycardia

Ketotic breath

Salpingitis or tubal

pregnancy

Suprapubic and iliac fossa pain, localised

tenderness

Nausea, vomiting

Fever

Torsion of testis/ovary Lower abdominal pain

Nausea, vomiting

Localised tenderness

98 • The gastrointestinal system

Dysphagia

Patients with dysphagia complain that food or drink sticks when

they swallow.

Ask about:

• 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

weight loss.

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

from the nose.

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

aspiration.

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.

Severity

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

causes (Box 6.3).

The acute abdomen

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

analgesia.