Rectal bleeding

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

Criterion Score

Age

<60 years 0

60–79 years 1

>80 years 2

Shock

None 0

Pulse >100 beats per minute and systolic

blood pressure >100 mmHg

1

Systolic blood pressure <100 mmHg 2

Comorbidity

None 0

Heart failure, ischaemic heart disease or

other major illness

2

Renal failure or disseminated malignancy 3

Endoscopic findings

Mallory–Weiss tear and no visible

bleeding

0

All other diagnoses 1

Upper gastrointestinal malignancy 2

Major stigmata of recent haemorrhage

None 0

Visible bleeding vessel/adherent clot 2

Total score

Pre-endoscopy (maximum score = 7) Score 4 = 14% mortality

pre-endoscopy

Post-endoscopy (maximum score = 11) Score 8+ = 25%

mortality post-endoscopy

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

Group Ltd.

Fig. 6.8 Yellow sclera of jaundice.

6.6 Common causes of jaundice

Increased bilirubin production

• Haemolysis (unconjugated hyperbilirubinaemia)

Impaired bilirubin excretion

• Congenital:

• Gilbert’s syndrome

(unconjugated)

• Hepatocellular:

• Viral hepatitis

• Cirrhosis

• Drugs

• Autoimmune hepatitis

• Intrahepatic cholestasis:

• Drugs

• Primary biliary cirrhosis

• Extrahepatic cholestasis:

• Gallstones

• Cancer: pancreas,

cholangiocarcinoma

102 • The gastrointestinal system

Groin swellings and lumps

Ask about:

• associated pain

• 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

abscess.

Past medical history

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)

is associated with diabetes and obesity. Ask about previous

abdominal surgery.

Drug history

Ask about all prescribed medications, over-the-counter medicines

and herbal preparations. Many drugs affect the gastrointestinal

tract (Box 6.8) and are hepatotoxic.

Family history

Inflammatory bowel disease is more common in patients with

a family history of either Crohn’s disease or ulcerative colitis.

Colorectal cancer in a first-degree relative increases the risk of

colorectal cancer and polyps. Peptic ulcer disease is familial but

this may be due to environmental factors, such as transmission of

Helicobacter pylori infection. Gilbert’s syndrome is an autosomal

dominant condition; haemochromatosis and Wilson’s disease are

autosomal recessive disorders. Autoimmune diseases, particularly

thyroid disease, are common in relatives of those with primary

biliary cirrhosis and autoimmune hepatitis. A family history of

diabetes is frequently seen in the context of NAFLD.

Social history

Ask about:

• Dietary history: assess the intake of calories and sources

of essential nutrients. For guidance, there are 9 kcal per g

of fat and 4 kcal per g of carbohydrates and protein.

• Food intolerances: patients with irritable bowel syndrome

often report specific food intolerances, including wheat,

dairy products and others. Painless diarrhoea may indicate

high alcohol intake, lactose intolerance or coeliac disease.

6.7 Urine and stool analysis in jaundice

Urine Stools

Colour Bilirubin Urobilinogen Colour

Unconjugated Normal – ++++ Normal

Hepatocellular Dark ++ ++ Normal

Obstructive Dark ++++ – Pale

6.8 Examples of drug-induced gastrointestinal conditions

Symptom Drug

Weight gain Oral glucocorticoids

Dyspepsia and

gastrointestinal bleeding

Aspirin

Non-steroidal anti-inflammatory drugs

Nausea Many drugs, including selective

serotonin reuptake inhibitor

antidepressants

Diarrhoea

(pseudomembranous colitis)