c

 




Approximately 75% of these consultations are for -organic symptoms. The
clinician's main task is therefore to recognize when  


 must be sought or
excluded, remembering that 20% of all cancers occur in the gastrointestinal tract
(esophagus 2%, stomach 5%, colon 10%, rectum 4%, others)
In „
 
 ,    and   make  a more
probable diagnosis. The clinician needs to recognize and treat these infections
promptly and also help with prevention by encouraging good hygiene.
c   c
 m 

 



Used to describe  !
 

such as heartburn, acidity, pain or
discomfort, nausea, wind, fullness or belching. Patients refer to all of these as
"

", but may also include other symptoms such as constipation and the
presence of undigested vegetable material in the stool. 'Indigestion' is common; 80%
of the population will say they have had indigestion at some time.
" "   


# 







   $

1.m dysphagia
2.m weight loss
3.m protracted vomiting
4.m anorexia
5.m Haematemesis or melaena.

Among these presented with alarm features, only a minority have significant
gastrointestinal pathology. Even among patients with a history of vomiting blood or
melaena, organic disease is by no means invariable. Nonetheless, concern about
missing treatable cancer is so great that most patients with alarm symptoms will be
recommended to undergo endoscopy.
r m 
  

 
These symptoms are described on page 249.
[ m  
Vomiting centres are located in the         of the 
 and
are
  
by:
1.m the chemoreceptor trigger zones (CTZs) in the floor of the fourth ventricle
2.m Vagal afferents from the gut.
3.m Directly by drugs, motion sickness and metabolic causes.
 
  

$

Ôm nausea - a feeling of wanting to vomit, often associated with 


including salivation, pallor and sweating
Ôm retching - a strong #   
# effort to vomit associated with
!
  
  
Ôm Vomiting - the expulsion of gastric contents through the mouth.

Many gastrointestinal (and non-gastrointestinal) conditions are associated with

vomiting (Table 6.1).
^
 
  and sometimes % vomiting suggest gastric outlet or
upper intestinal obstruction. A
 
 suggests low intestinal obstruction or
the presence of a gastrocolic fistula.

and
 
 
  of small amounts of gastric contents ˜ 
other abdominal symptoms are frequently 

r     is vomiting fresh or altered blood ('coffee-grounds').
 
 „
 is seen in
1.m Pregnancy.
2.m Alcohol dependence.
3.m Some metabolic disorders (e.g. uraemia).
ï m &  
Describes excessive wind.  


 
  belching, abdominal distension,
gurgling and the passage of flatus per rectum. Some of the
˜ ˜
 passes into
the intestine where most of it is absorbed, but some remains to be passed rectally.

  !   ! '
˜  
also produces a small amount of gas.  
 




 nitrogen, carbon dioxide, hydrogen and methane. It is normal
to pass rectal flatus up  r 
(
.
 ! )* +

 # *
 , 

1.m  

 



2.m 
: Viruses (influenza, norovirus), Bacterial (pertussis, urinary
infection).
3.m +  #





 Raised ICP, Vestibular disturbance,
Migraine
4.m  !: Uraemia, Hypercalcaemia, Diabetic ketoacidosis.
5.m  
: Antibiotics, Chemotherapy, Digoxin, Immunotherapy, Incretins,
Levodopa ,Opiates
6.m ,: AMI, Biliary colic
7.m 

8.m  
9.m  ,


u m   

 
Are not usually due to serious disease. 
  

 ; for example,
1.m A single episode of diarrhoea is commonly due to
  

 
,.
2.m  

   #   ˜ 
due to organic disease.
3.m †

  usually implies 


.
4.m  
  
 r*u

is most often due to an # 
.
Stool cultures can be useful but not always possible.
Patients often consider themselves constipated if their bowels are not open on most
days, though normal stool frequency is very variable-  [ 

  [ 

˜'. The difficult passage of hard stool is also regarded as constipation, irrespective
of stool frequency.   
  ˜  



 
   




) m !
   
Pain is stimulated mainly by the
  smooth muscle or organ capsules. An
apparent 'acute abdomen' can occasionally be due to referred pain from the chest, as in
pneumonia, or to metabolic causes, such as diabetic ketoacidosis or porphyria.
+  .    
˜ !
   
 

$

Ôm site, intensity, character, duration and frequency of the pain

Ôm aggravating and relieving factors
Ôm Associated symptoms, including non-gastrointestinal symptoms.
 /m 0 !
   
Ôm     is very common; it is often a dull ache, but sometimes sharp
and severe and may be related to food intake. Although   



is the commonest diagnosis, the symptoms of peptic ulcer disease can be
identical.
Ôm r 
 - a burning pain behind the sternum - is a common symptom of
reflux.
Ôm  „   may originate from the gall bladder or biliary tract.
Biliary pain can also be epigastric.    is typically intermittent, lasts a
few hours and remits spontaneously to recur weeks or months later. r   
      „ 

  and sometimes peptic ulcer
can present with pain in the right hypochondrium. Chronic, persistent or
constant pain in the right (or left) hypochondrium in a well-looking patient is a
frequent   
; this chronic pain is  due to gall bladder dis.
r/m ˜ !
   
1.m à
   
 
 is usually colonic in origin (e.g. acute
diverticulitis).    is most commonly associated with functional
bowel disorders.
2.m ^  „    occurs in a number of gynaecological
disorders and the differentiation from GI disease may be difficult.
3.m £       
 over a long period is  due to chronic
appendicitis and is most commonly functional.
4.m £   

  is a severe pain deep in the rectum that comes on suddenly
but lasts only for a short time. It is not due to organic disease.
um à„   


 abdominal pain with  1
tenderness which is  relieved by tensing
the abdominal muscles appears to arise from the abdominal wall itself.
+

    

i.m Nerve entrapment.
ii.m External hernias.
iii.m Entrapment of internal viscera (commonly omentum) within traumatic
ruptures of abdominal wall musculature.
 m , 
˜ 


i.m Anorexia describes 

. It is common in




 and
may be seen in 
 



, particularly anorexia nervosa. Anorexia
often accompanies cancer but is usually a late symptom 
 
 

.
ii.m  



 ˜ 

  


 ' and is a frequent
accompaniment of gastrointestinal diseases. Weight loss in   !
 is
primarily due to , . Weight loss with a normal or increased dietary
intake occurs with 

 
   !
 
. Weight loss
should ˜ 
be assessed objectively as patients' impressions are unreliable.