History – Gastrointestinal system

Symptoms Anorexia Weight loss Painful mouth Dysphagia Heartburn & reflux Dyspepsia Nausea & vomiting Haematemesis & melaena Abdominal pain Wind & flatulence Altered bowel habit Rectal bleeding Jaundice

Anorexia & weight loss Anorexia –Systemic disease –Malignancy (usually late feature) Weight loss (reduced caloric intake – 500 Kcal deficit per day = 0.5 kg loss per week) –Anorexia –Malabsorption –Diabetes (energy loss due to glycosuria) –Hyperthyroidism (increased energy expenditure)

Painful mouth Idiopathic –Aphthous ulcers Infections –Candidiasis –HSV –Coxsackie virus Misc –Leucoplakia –Trauma from teeth/ill-fitting dentures Skin disease –Lichen planus –Pemphigoid, pemphigus vulgaris

Painful mouth Systemic disease –Drug allergies – Sulphonamides, cytotoxics –Iron, folate, B12 deficiency –Acute leukaemia (leucopenia) –Inflammatory bowel disease

Dysphagia Oral –Mouth ulcers –Tonsilitis, pharyngitis –Peritonsillar abscess Neurological (liquids > solids) –CVA –Bulbar & pseudobulbar palsy Choking, regurgitation

Dysphagia Neuromuscular (solids > liquids) –Achalasia –Myasthenia gravis Mechanical (strictures) –Malignancy –Oesophagitis

Dysphagia Pain? Progressive? Duration? Previous history of heartburn Solids or liquids Level where food sticks regurgitation

Heartburn & reflux GORD/GERD Radiates upward Burning Occurs with lying flat Has to be differentiated from cardiac pain

Dyspepsia Peptic ulcer –Worse on empty stomach –Eased by eating –Nausea –Abdominal fullness worse after spicy/fatty meals

Nausea & vomiting Upper GI disorders Non GI causes –Drugs –Pregnancy –Diabetic ketoacidosis –Liver/renal failure –Vestibular disease –Raised intracranial pressure –After severe pain (MI)

Nausea/vomiting GI causes –Peptic ulcer –Intestinal obstruction Bile stained/non bile stained

Vomiting Medications With or without nausea Pain or dyspepsia Pain relieved by vomiting Relation to meal times Bile-stained?

Haematemesis / melaena Red – Fresh Coffee grounds – action of pepsin Vomiting fresh blood – above GI sphincter –Mallory Weiss

Melaena Upper GI bleed –Peptic ulcer, Mallory Weiss tear, varices Tarry stool Typical odour Drug history – Iron, NSAID. alcohol

Pain Parietal (localized) Visceral – deep seated, poorly localized Epigastric –Stomach, liver, pancreas Periumbilical –Small intestine

P ulcerBil colicAc. PancrR. colic Site Epigastr.Epi/R HypoEpi/L HypoLoin Onset GradualRapid incre.SuddenRapid incre. Character GnawingConstant Radiation BackBelow R scapula BackGroin Timing RemissionUnpred. Can enumerate Can Enumerate Discrete episode Duration <2 hrs4-24 hrs>24 hrs4-24 hrs ↑factor Stress, spice, NSAID, Alc. Unable to eatAlcohol, unable to eat ↓factor Food, vomit, antacids, Upright Severity Mild - modsevere

Non GI causes MI Dissection of aorta Pleurisy Herpes zoster Diabetes ketoacidosis Pelvic causes – salpingitis, tubal ectopic preg.

Distension Fat Flatus – obstruction Faeces – constipation (subacute obstruction) Fluid – ascites, ovarian tumors Fetus

Ascites Cirrhosis with portal HT Abdominal malignancy with peritoneal spread CHF Hypoproteinemia

Constipation Lack of diet fibre Irritable bowel synd Obstruction Drugs – opioids, iron Hypothyroidism Immobility - stroke

Diarrhoea Acute –GI –Drug induced Chronic –Irritable bowel –Inflammatory bowel disease –Giardiasis –Malignancy –Diabetes –Hyperthyroidism –Malabsorpiton

Rectal bleeding Hemorrhoids Anal fissure Colonic polyps Malignancy Inflammatory bowel disease Ischaemic colitis Diverticulitis

Jaundice Bil. > 3 mg/dl Prehepatic –Hemolysis –Pale lemon color –Stools and urine are normal

Hepatic jaundice –Dark urine –Stools normal colored Posthepatic –Pale stools –Dark urine

History for Jaundice Appetite/ wt loss Pain GI bleed Pruritus, dark urine Drug/alcohol Previous hepatitis Blood transfusions Sexual history Travel history Family history