SYMPTOMS AND SIGNS
Symptoms and signs of
upper gastrointestinal
disease
Maria GO Saunders
Cathryn M Edwards
Abstract
Patients with upper gastrointestinal (GI) disease present with diverse
symptoms, which are linked to significant morbidity and relatively few
reliable signs. Upper GI pathology may present as an acute abdomen,
when clinical diagnostic accuracy is approximately 50%. The aim of this
article is to provide a systematic approach for formulating a differential
diagnosis in patients with common symptoms and signs of upper GI dis-
ease, highlighting red flags for serious pathology.
Keywords belching; chest pain; dyspepsia; dysphagia; gastro-oesophageal
reflux; hiccups; nausea; upper abdominal pain; vomiting
Introduction
Upper gastrointestinal (GI) disease presents with a variety of
symptoms. It is essential that clinicians are able to formulate a
differential diagnosis, investigate appropriately and rule out
serious pathology urgently. This article will highlight important
differential diagnoses, and aims to give guidance on the assess-
ment of patients presenting with diverse symptom complexes.
Swallowing difficulties (dysphagia, odynophagia)
Dysphagia can be divided into two distinct groups: oropharyn-
geal and true oesophageal dysphagia. Identification of the type of
dysphagia is important as the likely pathology, investigations
and treatment pathways are different.
Oropharyngeal dysphagia
The voluntary, oropharyngeal swallow requires activation of a
complex neurological pathway, damage to any part of which can
lead to impairment. Clues in the history might be difficulty
initiating a swallow, choking, coughing or nasal regurgitation of
food. On examination, there may be delayed swallowing,
coughing, or a wet voice, due to pooling in the pharynx.
Dysarthria and cognitive impairment may point to an underlying
Maria GO Saunders BMBS MRCP is a Specialist Registrar in
Gastroenterology at South Devon Healthcare Foundation Trust, Torbay,
in the South West Peninsula Deanery, UK. Competing interests: none
declared.
Cathryn M Edwards MA D.Phil FRCP is Consultant Gastroenterologist and
Physician at South Devon Healthcare Foundation Trust, Torbay and
Senior Secretary of the British Society of Gastroenterology, UK. Her
main area of interest is Inflammatory Bowel Disease and paid
advisories relate to this subspecialty interest. Competing interests:
National Advisories for Ferring Pharmaceticals, MSD and Abbvie.
MEDICINE 43:3
What’s new?
C Eosinophilic oesophagitis (EO) is a condition that is fast
emerging as an important cause of dysphagia and may be
present in up to 15% of patients referred for upper gastroin-
testinal investigation of this symptom1
C In patients with gastroparesis refractory to medical treatment, a
gastric pacemaker can be inserted in selected patients. This has
been shown to improve symptoms and reduce the need for
nutritional support
neurological cause (see below). If a patient repeatedly chews
food and spits it out before swallowing, consider dementia or an
underlying psychiatric condition.
Oesophageal dysphagia
Impairment of the involuntary, oesophageal swallow leads to
compromised function and disorganized coordination of the
oesophageal musculature. This can occur as a result of me-
chanical obstruction or narrowing (stricture), achalasia with a
hypertonic lower oesophageal sphincter, oesophageal body dys-
motility, or systemic disorders including connective tissue dis-
orders such as systemic sclerosis; the latter may be evident on
systemic examination of the patient.
Oesophageal dysphagia can be progressive or acute. Com-
plete acute dysphagia, where a patient is unable to swallow
their saliva, is a medical emergency requiring hospital admis-
sion. Food bolus impaction is the most common cause of the
sudden onset of complete or partial dysphagia and an oeso-
phagogastroduodenoscopy (OGD), with bolus removal, should
be performed within 24 hours.2 Prolonged food bolus impac-
tion can result in oesophageal ulceration and potential perfo-
ration. A chest X-ray is indicated if history suggests ingestion of
a sharp object, or if there are concerns of pharyngeal
perforation.
In young patients with atopy or recurrent food bolus
obstruction, consider eosinophilic oesophagitis (EO). Long-
standing EO may present with oesophageal sticturing. Biopsies
from the mid- and distal oesophagus support the diagnosis and
treatments include topical corticosteroids (i.e. swallowing a
metered dose of corticosteroid aerosol).
Dysphagia to solids, particularly if restricted to certain foods,
is likely to indicate an obstructive lesion. However, if dysphagia
is equal to liquids and solids, or intermittent, consider dysmo-
tility or inflammatory causes (see below). Progressive dysphagia
is a red-flag symptom, often indicating a worsening obstructive
lesion, usually a peptic stricture or oesophageal carcinoma. Ask
patients about the presence or absence of reflux symptoms, the
duration of symptoms and regurgitation of undigested food after
the initial swallow. Do not forget systemic symptoms such as
weight loss, anorexia and change of taste, which may indicate
underlying malignancy.
Globus sensation is a diagnosis of exclusion where patients
describe a ‘lump’ in their throat, like a ‘boiled sweet’. This is
usually not related to food ingestion, but may occur on swal-
lowing saliva. This can be intermittent and may occur during
times of stress.
141 Ó 2015 Published by Elsevier Ltd.
 SYMPTOMS AND SIGNS

Odynophagia Around 10% of referrals with dysphagia/dyspepsia under the 2-

Odynophagia (painful swallowing) is often mistaken for week wait for upper GI cancer are found to have a malignant
dysphagia. If odynophagia is sudden in onset, consider ingested diagnosis.3 The presence of candidiasis without obvious cause
(caustic) substances and foreign bodies. An emergency OGD may should raise the possibility of HIV or occult underlying
be required to assess mucosal damage to the upper GI tract, malignancy.4
which aids prognostication, assessment of the development of
strictures and possible therapy (removal of foreign bodies). Dyspepsia and reflux
The leading cause of odynophagia is candidiasis. Odynopha-
Dyspepsia is common; around 40% of adults experience this
gia may be preceded by other symptoms that may point to the
symptom annually.5 It is defined as pain or discomfort in the
aetiology of the pain (e.g. heartburn may indicate reflux oeso-
upper abdomen and may be associated with other symptoms,
phagitis). A drug history is essential (e.g. corticosteroids leading
such as early satiety, bloating, borborygmi or heartburn. A clear
to oesophageal candidiasis or bisphosphonates causing oeso-
description is helpful in the history as patients may have very
phageal ulceration/stricturing) (Table 1).
different ideas of ‘indigestion pain’ than those ascribed to
Investigation pathway dyspepsia by the medical profession. It is important to establish
Patients with oropharyngeal dysphagia should undergo a thor- the nature and site of the pain, exacerbating and relieving factors,
ough neurological examination and assessment from the speech relation to food and the benefit of medications such as proton
and language team. They are then investigated with video- pump inhibitors. Pain may be nocturnal, periodic or radiating
fluoroscopy and may need referral to a neurologist for consid- through to the back, sometimes with post-prandial exacerbation.
eration of further investigations, as appropriate. Associated symptoms such as vomiting, nausea, weight loss,
All patients with oesophageal dysphagia should be urgently reflux and belching should be part of direct questioning. A drug
investigated, usually with an OGD under the 2-week wait rule, if history may also support diagnosis, for example in patients tak-
malignancy is suspected. If dysmotility is the suspected diag- ing non-steroidal anti-inflammatory drugs.
nosis, patients should have a barium swallow examination and If a patient complains of worsening pain, early satiety,
be considered for oesophageal manometry. Patients with reflux persistent vomiting and systemic features, such as anaemia and
often describe the sensation of difficulty with swallowing. unintentional weight loss, they should be investigated urgently.
Abnormal laboratory findings, such as anaemia, or a raised
platelet count or serum C-reactive protein, increase the likelihood
Differential diagnosis of swallowing problems of organic pathology such as malignancy, inflammatory disease
or bleeding peptic ulcer disease.
Category Differential
Investigation pathway
Extrinsic Thyroid mass, thoracic aortic aneurysm,
In certain circumstances, dyspepsia can be a red-flag symptom
compression osteophytes and skeletal abnormalities,
and warrant urgent investigation. If patients present with
enlarged left atrium, nodal mass,
dyspepsia and upper GI bleeding, they should be referred ur-
lung cancer
gently, on the same day, to a gastroenterologist.6
Obstructive Pouch, diverticulum, web, Schatzki ring,
In patients who do not meet the criteria for urgent referral,
benign stricture, radiation stricture,
testing for Helicobacter pylori and eradication, if positive, fol-
oesophageal cancer, food bolus
lowed by a trial of proton pump inhibitor is an appropriate
Inflammatory Eosinophilic oesophagitis, chemical
management strategy. Recent guidelines state that patients of any
ingestion, gastro-oesophageal reflux
age with gastro-oesophageal symptoms that are unexplained or
disease, pill oesophagitis
do not respond to treatment should be referred to a gastroen-
Infective CMV, HSV, candida
terologist and considered for an OGD.6 Endoscopy may reveal a
Motility Achalasia, oesophageal dysmotility,
hiatus hernia, reflux oesophagitis, Barrett’s oesophagus, peptic
scleroderma, connective tissue disorders
ulcer disease or an underlying malignancy.
Neuromuscular Dementia, cerebral trauma, stroke,
In patients with a normal endoscopic examination, especially
GuillaineBarre syndrome, movement
those whose dyspepsia is associated with other systemic fea-
disorders (e.g. Huntington’s chorea),
tures, such as weight loss or diarrhoea, rarer causes should be
multiple sclerosis, encephalopathy,
considered; these include coeliac disease, pancreatic pathology,
motor neurone disease, brainstem
‘intestinal angina’ (mesenteric ischaemia) and metabolic causes
tumours
(e.g. hypercalcaemia). Infiltrative conditions (e.g. sarcoid,
Psychological Anxiety, depression, globus sensation
Crohn’s disease) may be detected on biopsy of the gastric mu-
Other Xerostomia
cosa, or occasionally have a recognizable macroscopic appear-
Odynophagia Candida, viral oesophagitis (HSV, CMV),
ance at endoscopy (e.g. ‘bamboo stomach’ in Crohn’s disease of
ingestion of corrosive substance, foreign
the upper GI tract).
body, dissecting intramural oesophageal
Non-ulcer dyspepsia is a diagnosis of exclusion and should be
haematoma (rare)
diagnosed according to the Rome III criteria for functional GI
CMV, cytomegalovirus; HSV, herpes simplex virus. conditions.7 H. pylori status should be checked as around 7% of
patients will respond to eradication therapy.8,9
Table 1

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 SYMPTOMS AND SIGNS
Acute abdominal pain
Upper GI symptoms presenting acutely form part of the differ-
ential diagnosis of the acute abdomen. Remember to ask about
site, onset, duration, radiation, and exacerbating and relieving
factors in relation to the pain. Direct questions should cover
previous abdominal surgery, nausea, vomiting and abdominal
distension. It is relevant to ask about bowel habit in this context
(including passing flatus) as subacute obstruction can present
with upper abdominal pain.
When patients complain of epigastric pain, it is important to
rule out abdominal wall pain. This is confirmed by replication of
pain on palpation of the abdominal wall whilst the patient tenses
the abdominal muscles, such as when sitting up (Carnett’s sign)
(Table 2).
Retrosternal chest pain
Oesophageal pain can mimic cardiac chest pain, as it can radiate
to the neck and be described as ‘heavy’. As a result, patients
should be investigated for cardiac pathology before an oeso-
phageal cause is considered. Oesophageal spasm, often triggered
by oesophageal reflux, is an excellent mimic for angina or
myocardial infarction, and can be severe. Oesophageal pain may
be associated with food but should not be triggered by exertion.
A dissecting intramural oesophageal haematoma (rare) can also
mimic angina; the diagnosis is made by endoscopy and a
consistent history.
If a patient presents unwell, haemodynamically compromised
or with severe chest pain, particularly following vomiting, in-
vestigations should exclude oesophageal rupture (Boorhaeve’s
syndrome). A chest X-ray may reveal a pneumomediastinum, or
pleural effusion with or without an associated pneumothorax.
Gastric volvulus is often overlooked as a diagnosis. It usually
presents with small-volume haematemesis and severe epigastric
or lower chest pain. Complete volvulus is a surgical emergency
and patients may have concurrent dysphagia. A chest X-ray will
often demonstrate the hernia, but no other features.
Investigation pathway
Investigation of patients with acute retrosternal chest pain de-
pends on the presentation, but should usually begin with a
chest X-ray and ECG to rule out non-GI causes of this symptom.
After discussion with a gastroenterologist, an OGD and/or
thoracic/abdominal computed tomography (CT) scan may be
indicated.
Nausea and vomiting
Nausea and vomiting are complex symptoms with a variety of
causes, including local obstruction of the GI tract, a peripheral
stimulus to vomiting or centrally mediated mechanisms, relayed
through the chemoreceptor trigger zone in the medulla. The
latter may be as diverse as drug-induced (such as chemotherapy-
induced nausea and vomiting) or neurologically induced (such as
raised intracranial pressure). When assessing patients with
nausea, it is essential to differentiate this from anorexia or food
revulsion. It is also important to ascertain if a patient has true
vomiting, which is preceded by hypersalivation and then
contraction of the abdominal muscles, or regurgitation, which is
effortless.
MEDICINE 43:3
Vomiting
Vomiting is a common symptom and, as such, occurs in a variety
of circumstances, including pregnancy. Remember to consider
simple causes such as gastroenteritis, especially in patients who
give an association with ingestion of a suspect foodstuff, or
where other people are unwell. Drugs, including non-
prescription or recreational drugs, are a common trigger for
vomiting. Excess alcohol intake can lead to nausea and vomiting,
either from bingeing or long-term alcohol misuse.
The timing of vomiting in relation to food can be useful: in
immediate or early vomiting, consider psychological causes; if it
is delayed by hours, consider mechanical causes, such as small
bowel obstruction, or ileus.
Anxiety and stress can lead to nausea and vomiting, as can
pain from any cause. It is also important to ask all patients
specifically about eating disorders, as they are unlikely to
mention this without direct questioning. In those with recurrent
attacks, consider cyclical vomiting syndrome (CVS), which pre-
sents with repeated attacks of severe nausea, vomiting and
physical exhaustion, lasting from hours to days. These attacks
are similar in their nature, but may vary between patients. Be-
tween attacks, the patient feels well. The condition presents more
commonly in childhood, affecting 3 in 100,000 children, but can
present in adulthood and may last from months to decades.10
CVS is a clinical diagnosis and organic causes should be
excluded before a diagnosis is confirmed. It is strongly associated
with migraine and its treatment is similar, for example, tryptans
during an attack and propranolol as prophylaxis.
Coffee-ground vomiting can be a sign of upper GI bleeding,
but may also reflect gastric stasis, caused by gastric outlet
obstruction or gastroparesis. To justify use of the term ‘coffee-
ground’, the vomit must be black, as opposed to merely dark. If
the patient presents acutely with large-volume, coffee-ground
vomiting or fresh haematemesis, associated with severe pain,
consider gastric volvulus (see above).
Patients with gastroparesis present with abdominal disten-
sion, nausea and large-volume vomiting, sometimes with asso-
ciated weight loss and anorexia. Symptoms are difficult to
control, and often refractory to medical treatment. In patients
with diabetic gastroparesis, the mainstay of treatment is tight
diabetic control. If medical management is unsuccessful, jejunal
feeding may be necessary. For patients who are refractory to
treatment, a gastric pacemaker can be inserted. This device is
similar in size to a cardiac pacemaker and is usually placed in the
abdominal wall. In studies, following gastric pacemaker inser-
tion, patients had a statistically significant improvement in
symptoms, a reduction in need for nutritional support and a
small improvement in measured gastric emptying times.11
Symptoms that point towards a neurological cause for vom-
iting are headache, double vision or gait abnormalities. Red-flag
symptoms are the absence of any warning, and vomiting that
occurs early in the morning or is forceful in nature. Such patients
should be referred for urgent cross-sectional imaging of the brain.
Associated vertigo or tinnitus indicates possible vestibular pa-
thology (Table 3).
Regurgitation
Regurgitation is a voluntary or involuntary return of partly
digested food into the oropharynx. It is important to differentiate
143 Ó 2015 Published by Elsevier Ltd.
 SYMPTOMS AND SIGNS
Differential diagnosis of upper abdominal pain
Category Differential diagnoses
Gastrointestinal Perforated viscus, pancreatitis, biliary colic,
cholecystitis, sphincter of Oddi dysfunction
Infective Pneumonia (especially right lower lobe),
mesenteric adenitis, dermatological herpes
zoster (pre-rash, thoracic distribution),
Lyme disease radiculopathy (very rare)
Musculoskeletal Prolapsed intervertebral disc, abdominal
wall pain
Cardiovascular Myocardial infarction (high index of suspicion
in patients with diabetes), mesenteric ischaemia,
splenic infarction, aortic aneurysm
Metabolic Diabetic ketoacidosis, addisonian crisis, porphyria
Other Sickle cell crisis, splenic rupture (consider in
context with EBV)
EBV, EpsteineBarr virus.
Table 2
this from vomiting, as patients struggle to do this unless asked
specifically.
If regurgitation is associated with reflux symptoms and worse
on lying flat, think about gastro-oesophageal reflux disease or
hiatus hernia. If involuntary, with undigested food, consider an
oesophageal pouch, because the investigation of choice may be a
barium swallow, rather than an OGD, as there is an increased
risk of perforation when performing endoscopy on these patients.
Although regurgitation can be pathological, it can also be due to
psychological causes and these should be considered and
addressed if no cause is found.
Investigation pathway
The cause of vomiting is often evident once a careful history
has been obtained, and pregnancy testing is mandatory for all
females of childbearing age. However, if vomiting persists
further investigation is warranted, usually beginning with an
OGD and a laboratory workup to exclude metabolic abnor-
malities. If these reveal no abnormality, the next step would
be abdominal imaging and, in selected patients, gastric
emptying studies. If symptoms suggest a neurological cause,
an urgent CT scan of head would be the initial investigation of
choice.
Belching
Gastric belching occurs when there is a transient relaxation of the
lower oesophageal sphincter, allowing gas from the stomach to
escape. This is triggered by distension of the proximal stomach; it
is an involuntary reflex and normally occurs 20e30 times a day.
Supragastric belching occurs due to air ingested immediately
before it is expelled; diaphragmatic contractions lead to a
negative pressure in the oesophagus causing air ingestion. Pa-
tients audibly swallow, then immediately expel air, often with
great force and generate a loud noise. This is behavioural, not a
reflex, and is the cause of excessive belching. The underlying
MEDICINE 43:3
Differential diagnosis of nausea and vomiting
Category Differential diagnoses
Central Migraine, traumatic brain injury, meningitis,
encephalitis, space-occupying lesion,
cerebrovascular events, intracerebral bleeds
Vestibular Labyrynthitis, benign paroxysmal positional
vertigo, Meniere’s disease, acoustic neuroma
Obstructive Gastric outlet obstruction, small bowel
obstruction
Gastrointestinal Gastroenteritis, peptic ulcer disease,
cholecystitis, pancreatitis, severe constipation,
gastroparesis, pseudo-obstruction, gastric
dysrhythmia
Psychological Anxiety, stress, eating disorders
Metabolic Hypercalcaemia, hypothyroidism, uraemia,
adrenal insufficiency, hyperthyroidism,
hypopituitarism
Malignancy Gastric cancer, pancreatic cancer, renal cancer,
small cell lung cancer, ovarian cancer,
carcinomatous peritonitis, VIPoma, carcinoid
Drugs Opiates, antibiotics, anaesthetics, alcohol,
cannabinoids, chemotherapy, NSAIDs,
antidepressants, anti-arrhythmics, oestrogen/
progesterone, digoxin, metformin, theophylline,
exenatide
Pregnancy Normal physiological response, hyperemesis
gravidarum (molar pregnancy, multiple birth),
acute fatty liver disease of pregnancy,
pre-eclampsia
Other Pain, myocardial infarction, gastroparesis,
motion sickness, post-surgical, cyclical
vomiting syndrome, nephrolithiasis, chronic
mesenteric ischaemia
VIP, vasoactive intestinal polypeptide; NSAID, non-steroidal anti-
inflammatory drug.
Table 3
cause of this is usually psychogenic, resulting from stress or
anxiety. Many patients are genuinely unaware of the behavioural
pattern they have adopted, so gentle behavioural therapy is
appropriate. If belching is associated with other symptoms,
consider further investigation as this may indicate an underlying
pathology.
Hiccups
A multitude of conditions can lead to hiccups, which should be
investigated if the symptom persists (Table 4).
Post-gastric surgery symptoms
Following gastric surgery, patients can experience a variety of
symptoms, including early satiety, dyspepsia, reflux and vomit-
ing. This is particularly true for patients following a gastric
bypass, as their gastric remnant is smaller than they are used to
and they need to reduce their oral intake to accommodate this.
144 Ó 2015 Published by Elsevier Ltd.
 SYMPTOMS AND SIGNS

Signs of upper GI disease

Differential diagnosis of hiccups
Examination of patients with symptoms of upper GI pathology is
Category Differential usually normal. However, there are some useful pointers to un-
derlying conditions (Table 5). A
Neurological Space-occupying lesion, infective,
multiple sclerosis, arterial-venous
malformations REFERENCES
Vagal/phrenic nerve Neck mass, abnormality of the 1 Mackenzie SH, Go M, Chadwick B, et al. Eosinophilic oesophagitis in
irritation diaphragm patients presenting with dysphagia: a prospective analysis. Aliment
Gastrointestinal Gastric cancer, pancreatic cancer, Pharmacol Ther 2008; 28: 1140e6.
gastro-oesophageal reflux disease 2 American Society for Gastrointestinal Endoscopy. Management of
Thoracic Lymphadenopathy, aortic aneurysm, ingested foreign bodies and food impactions. Gastrointest Endosc
pneumonia 2011; 73: 1085e91.
Cardiac Myocardial infarction, pericarditis 3 Wireko MB, Subramanian V, Ragunath K. The two week wait (2WW)
Metabolic Uraemia, hyponatraemia referral for upper gastrointestinal cancer: predictors and prevalence of
Postoperative General anaesthetic induced, visceral non-upper gastrointestinal cancers in those with negative gastros-
irritation copy. Gut 2011; 60: A47. http://dx.doi.org/10.1136/gut.2011.239301.
Drugs Benzodiazepines, dexamethasone, 93 (accessed 14 Aug 2014).
methyldopa 4 British HIV Association. British Association for Sexual Health and HIV.
Psychogenic Anxiety, stress British Infection Society. UK National Guidelines for HIV testing. 2008
(accessed 14 Aug 2014), http://www.bhiva.org/hivtesting2008.aspx.
Table 4 5 National Institute for Health and Care Excellence. Dyspepsia: man-
agement of dyspepsia in adults in primary care. http://www.nice.org.
Following gastric resection or pyloroplasty, patients can uk/guidance/cg17/resources/guidance-dyspepsia-pdf (accessed 14
experience dumping syndrome. This results from rapid gastric Aug 2014).
emptying leading to hypovolaemia due to the hyperosmolar 6 National Institute for Health and Care Excellence. Dyspepsia and
enteric load. The characteristic symptoms occur 15e30 minutes gastro-oesophageal reflux disease: Investigation and management of
after a meal, and comprise tiredness, syncope and peripheral dyspepsia, symptoms suggestive of gastro-oesophageal reflux dis-
vasodilatation, sweating, palpitations, nausea, vomiting, borbo- ease, or both. http://www.nice.org.uk/guidance/cg184/resources/
rygmi and diarrhoea. guidance-dyspepsia-and-gastrooesophageal-reflux-disease-pdf
(accessed 26 Sept 2014).
7 Rome Foundation. Rome III diagnostic criteria for functional gastro-
Differential diagnosis using signs of GI disease intestinal disorders. http://www.romecriteria.org/assets/pdf/19_
RomeIII_apA_885-898.pdf (accessed 14 Aug 2014).
Sign Differential 8 Moayyedi P, Soo S, Deeks J, et al. Eradication of Helicobacter pylori
for non-ulcer dyspepsia. Cochrane Database Syst Rev 2006. Issue 2.
Neck mass Thyroid goitre, lymphadenopathy
Art. No.:CD002096.
Virchow’s node Intra-abdominal malignancy
9 Mazzoleni LE, Sander GB, Francesconi CF, et al. Helicobacter pylori
Epigastric mass Hepatomegaly, gastric mass,
eradication in functional dyspepsia: HEROES trial. Arch Intern Med
pancreatic mass, lymphadenopathy,
2001; 171: 1929e36.
peritoneal mass
10 Hejazi RA, McCallum RW. Review article: cyclical vomiting syndrome
Facial flushing VIPoma, carcinoid
in adults e rediscovering and redefining an old entity. Aliment
Murphy’s sign Cholecystitis
Pharmacol Ther 2011; 34: 263e73.
Carnett’s sign Abdominal wall pain
11 National Institute for Health and Care Excellence. Gastroelectrical
Neurofibromatosis Rare cause of small bowel
stimulation for gastroparesis. http://www.nice.org.uk/guidance/
obstruction
ipg489/resources/guidance-gastroelectrical-stimulation-for-
Necrolytic migratory erythema Glucagonoma
gastroparesis-pdf (accessed 14 Aug 2014).
Migratory thrombophlebitis Pancreatic cancer
Sister Mary Joseph nodule Intra-abdominal malignancy
Practice points
Acanthosis nigrans Diabetes, gastric cancer
Succession splash Gastric outlet obstruction, gastric C Upper GI disease-related symptoms are common.
stasis C A focused history is key to compiling an appropriate differential
Cullen’s sign (oedema and Pancreatitis, retroperitoneal
diagnosis.
bruising around the umbilicus) haematoma C Symptoms of upper GI disease can be associated with disorders
and Grey Turner’s sign (bruising
of other body systems and must be considered if no GI cause is
in the flanks)
identified.
GI, gastrointestinal; VIP, vasoactive intestinal polypeptide. C Red-flag symptoms should be actively sought and an urgent
referral made if found.
Table 5

MEDICINE 43:3 145 Ó 2015 Published by Elsevier Ltd.