stomach and eased by eating is typical of peptic ulceration. The

patient may indicate a single localised point in the epigastrium

(pointing sign), and complain of nausea and abdominal fullness

1 kg/week (7000 kcal ≅ 1 kg of fat). Greater weight loss during

the initial stages of energy restriction arises from salt and water

loss and depletion of hepatic glycogen stores, not from fat

loss. Rapid weight loss over days suggests loss of body fluid

as a result of vomiting, diarrhoea or diuretics (1 L of water =

1 kg). Check current and previous weight records to confirm

apparent weight loss on examination (loose-fitting clothes, for

example).

Pain

Painful mouth

Causes of sore lips, tongue or buccal mucosa include:

• deficiencies, including iron, folate, vitamin B12 or C

• dermatological disorders, including lichen planus

(Fig. 6.3A)

• chemotherapy

• aphthous ulcers (Fig. 6.3B)

• infective stomatitis

• inflammatory bowel disease and coeliac disease,

associated with mouth ulcers.

Heartburn and reflux

Heartburn is a hot, burning retrosternal discomfort.

To differentiate heartburn from cardiac chest pain, ask about

associated features:

• character of pain: burning

• radiation: upward

• precipitating factors: lying flat or bending forward

• associated symptoms:

• waterbrash (sudden appearance of fluid in the mouth

due to reflex salivation as a result of

gastro-oesophageal reflux disease (GORD) or, rarely,

peptic ulcer disease)

• the taste of acid appearing in the mouth due to reflux/

regurgitation.

When heartburn is the principal symptom, GORD is the most

likely diagnosis.

Left adrenal gland Right kidney

Gallbladder

Stomach

Pancreas

Intestines

Spine

Aorta

Liver

Rib

Fig. 6.2 Normal computed tomogram of the abdomen at L1 level.

A

B

Fig. 6.3 Some causes of a painful mouth. A Lichen planus. B Small,

‘punched-out’ aphthous ulcer (arrow).

96 • The gastrointestinal system

Character

Colicky pain lasts for a short time (seconds or minutes), eases

off and then returns. It arises from hollow structures, as in small

or large bowel obstruction, or the uterus during labour.

Biliary and renal ‘colic’ are misnamed, as the pain is rarely

colicky; pain rapidly increases to a peak and persists over several

hours before gradually resolving. Dull, constant, vague and poorly

localised pain is more typical of an inflammatory process or

infection, such as salpingitis, appendicitis or diverticulitis (Box 6.2).

Radiation

Pain radiating from the right hypochondrium to the shoulder or

interscapular region may reflect diaphragmatic irritation, as in

acute cholecystitis (see Fig. 6.5). Pain radiating from the loin

to the groin and genitalia is typical of renal colic. Central upper

abdominal pain radiating through to the back, partially relieved by

that is worse after fatty or spicy meals. ‘Fat intolerance’ is common

with all causes of dyspepsia, including gallbladder disease.

Odynophagia

Odynophagia is pain on swallowing, often precipitated by drinking

hot liquids. It can be present with or without dysphagia (see below)

and may indicate oesophageal ulceration or oesophagitis from

gastro-oesophageal reflux or oesophageal candidiasis. It implies

intact mucosal sensation, making oesophageal cancer unlikely.

Abdominal pain

Characterise the pain using SOCRATES (see Box 2.2). Ask about

the characteristics described here.

Site

Visceral abdominal pain from distension of hollow organs,

mesenteric traction or excessive smooth-muscle contraction is

deep and poorly localised in the midline. The pain is conducted

via sympathetic splanchnic nerves. Somatic pain from the parietal

peritoneum and abdominal wall is lateralised and localised to the

inflamed area. It is conducted via intercostal nerves.

Pain arising from foregut structures (stomach, pancreas, liver

and biliary system) is localised above the umbilicus (Fig. 6.4).

Central abdominal pain arises from midgut structures, such as

the small bowel and appendix. Lower abdominal pain arises

from hindgut structures, such as the colon. Inflammation may

cause localised pain: for example, left iliac fossa pain due to

diverticular disease of the sigmoid colon.

Pain from an unpaired structure, such as the pancreas, is

midline and radiates through to the back. Pain from paired

structures, such as renal colic, is felt on and radiates to the

affected side (Fig. 6.5). Torsion of the testis may present with

abdominal pain (p. 232). In females, consider gynaecological

causes like ruptured ovarian cyst, pelvic inflammatory disease,

endometriosis or ectopic pregnancy (p. 218).

Onset

Sudden onset of severe abdominal pain, rapidly progressing to

become generalised and constant, suggests a hollow viscus

perforation (usually due to colorectal cancer, diverticular disease

or peptic ulceration), a ruptured abdominal aortic aneurysm or

mesenteric infarction.

Torsion of the caecum or sigmoid colon (volvulus) presents

with sudden abdominal pain associated with acute intestinal

obstruction.

Foregut – pain localises

to epigastric area

Midgut – pain localises

to periumbilical area

Hindgut – pain localises

to suprapubic area

Fig. 6.4 Abdominal pain. Perception of visceral pain is localised to the epigastric, umbilical or suprapubic region, according to the embryological origin of

the affected organ.

Right shoulder

Gallbladder

Diaphragm

Tip of scapula

Ureter

Inguinal canal

Gallbladder pain

Diaphragmatic pain

Ureteric pain

Fig. 6.5 Characteristic radiation of pain from the gallbladder,

diaphragm and ureters.

The history • 97

6

sitting forward, suggests pancreatitis. Central abdominal pain that

later shifts into the right iliac fossa occurs in acute appendicitis.

The combination of severe back and abdominal pain may indicate

a ruptured or dissecting abdominal aortic aneurysm.

Associated symptoms

Anorexia, nausea and vomiting are common but non-specific

symptoms. They may accompany any very severe pain but

conversely may be absent, even in advanced intra-abdominal

disease. Abdominal pain due to irritable bowel syndrome,

diverticular disease or colorectal cancer is usually accompanied

by altered bowel habit. Other features such as breathlessness

or palpitation suggest non-alimentary causes (Box 6.3).

Hypotension and tachycardia following the onset of pain

suggest intra-abdominal sepsis or bleeding: for example, from a

peptic ulcer, a ruptured aortic aneurysm or an ectopic pregnancy.

Timing

During the first 1–2 hours after perforation, a ‘silent interval’

may occur when abdominal pain resolves transiently. The initial

chemical peritonitis may subside before bacterial peritonitis

becomes established. For example, in acute appendicitis, pain

is initially periumbilical (visceral pain) and moves to the right iliac

fossa (somatic pain) when localised inflammation of the parietal

peritoneum becomes established. If the appendix ruptures,

generalised peritonitis may develop. Occasionally, a localised

appendix abscess develops, with a palpable mass and localised

pain in the right iliac fossa.

Change in the pattern of symptoms suggests either that the

initial diagnosis was wrong or that complications have developed.

In acute small bowel obstruction, a change from typical intestinal

colic to persistent pain with abdominal tenderness suggests

intestinal ischaemia, as in strangulated hernia, and is an indication

for urgent surgical intervention.

Abdominal pain persisting for hours or days suggests an

inflammatory disorder, such as acute appendicitis, cholecystitis

or diverticulitis.

6.2 Diagnosing abdominal pain

Disorder

Peptic ulcer Biliary colic Acute pancreatitis Renal colic

Site Epigastrium Epigastrium/right

hypochondrium

Epigastrium/left

hypochondrium

Loin