Gastrointestinal Emergencies

New onset of severe constipation or recent change of bowel habit in elderly patient Rectal bleeding Unexplained anaemia Family history of colorectal cancer or inflammatory bowel disease Tenesmus Weight loss Vomiting New onset of severe constipation or recent change of bowel habit in elderly patient Rectal bleeding Unexplained anaemia Family history of colorectal cancer or inflammatory bowel disease Tenesmus Weight loss Vomiting

Colonic: diverticulitis (sigmoid); acute appendicitis (with situs inversus); perforated colonic cancer; Crohn’s colitis; ischaemic colitis; colonic obstruction Vascular: aortic aneurysm: leaking; ruptured; ruptured iliac artery aneurysm Gynaecological: ovarian cyst accident (including mittelschmerz),-torsion, rupture); endometriosis;pelvic inflammatory disease(salpingitis); ectopic pregnancy Renal: renal/ureteric colic; pyelonephritis Psoas abscess Testicular torsion Inguinal hernia: incarcerated; strangulated Seminal vesiculitis Rectus sheath haematoma Herpes zoster Colonic: diverticulitis (sigmoid); acute appendicitis (with situs inversus); perforated colonic cancer; Crohn’s colitis; ischaemic colitis; colonic obstruction Vascular: aortic aneurysm: leaking; ruptured; ruptured iliac artery aneurysm Gynaecological: ovarian cyst accident (including mittelschmerz),-torsion, rupture); endometriosis;pelvic inflammatory disease(salpingitis); ectopic pregnancy Renal: renal/ureteric colic; pyelonephritis Psoas abscess Testicular torsion Inguinal hernia: incarcerated; strangulated Seminal vesiculitis Rectus sheath haematoma Herpes zoster

Liver disease Previous episodes of jaundice Blood transfusion Intravenous drug use Alcohol history Sexual history Travel history Drug history, including over-the-counter, recreational and herbal Contacts: environmental and food exposure Liver disease Previous episodes of jaundice Blood transfusion Intravenous drug use Alcohol history Sexual history Travel history Drug history, including over-the-counter, recreational and herbal Contacts: environmental and food exposure

Adults Two or more of the following for at least 12 weeks in the preceding 12 months: Straining during >25% of bowel movements Lumpy or hard stools for >25% of bowel movements Sensation of incomplete evacuation for >25% of bowel movements Sensation of anorectal blockage for >25% of bowel movements Manual manoeuvres to facilitate >25% of bowel movements 25% of bowel movements Lumpy or hard stools for >25% of bowel movements Sensation of incomplete evacuation for >25% of bowel movements Sensation of anorectal blockage for >25% of bowel movements Manual manoeuvres to facilitate >25% of bowel movements <3 bowel movements per week Loose stools not present, and insufficient criteria for irritable bowel syndrome met

Features Jaundice Ascites Peripheral oedema Encephalopathy (confusion, flapping tremor, constructional apraxia); cerebral oedema Coagulopathy Upper gastrointestinal bleeding Acute kidney injury Sepsis Previously normal liver function Jaundice Ascites Peripheral oedema Encephalopathy (confusion, flapping tremor, constructional apraxia); cerebral oedema Coagulopathy Upper gastrointestinal bleeding Acute kidney injury Sepsis Previously normal liver function Causes Hepatotoxicity: dose dependent: paracetamol overdose, methyldioxymethamphetamine; idiosyncratic drug reactions (isoniazid; NSAIDs, antiepileptic drugs, antibi​otics-rifampicin) Acute viral hepatitis: hepatitis A, B, C, D, E; cytomegalovirus, adenovirus, haemorrhagic fever viruses, herpes simplex virus, Epstein-Barr virus, paramyxovirus Autoimmune hepatitis Acute steatosis syndromes (extensive hepatocyte infiltration with fat microdroplets and minimal hepatocellular necrosis): acute fatty liver of pregnancy; Reye’s syndrome; acute alcoholic hepatitis Toxins: Amanita phalloides (mushroom ingestion), Bacillus cereus, yellow phosphorus, organic solvents (hydrocarbons, eg carbon tetrachloride) Vascular: ischaemic hepatitis (shock liver); hepatic vein thrombosis (Budd-Chiari syndrome); hepatic veno-occlusive disease; portal vein thrombosis; hepatic artery thrombosis; congestive heart failure; right heart failure Metabolic: α1-antitrypsin deficiency; hereditary fructose intolerance; galactosaemia; LCAT (lecithin-cholesterol acyltransferase) deficiency; Reye’s syndrome; hepatolenticular degeneration; tyrosinaemia Malignancy: primary liver tumours (hepatocellular carcinoma, cholangiocarcinoma); secondary tumours (extensive hepatic metastases from adenocarcinoma, melanoma, lymphoma); leukaemia Miscellaneous: adult-onset Still’s disease; heatstroke Hepatotoxicity: dose dependent: paracetamol overdose, methyldioxymethamphetamine; idiosyncratic drug reactions (isoniazid; NSAIDs, antiepileptic drugs, antibi​otics-rifampicin) Acute viral hepatitis: hepatitis A, B, C, D, E; cytomegalovirus, adenovirus, haemorrhagic fever viruses, herpes simplex virus, Epstein-Barr virus, paramyxovirus Autoimmune hepatitis Acute steatosis syndromes (extensive hepatocyte infiltration with fat microdroplets and minimal hepatocellular necrosis): acute fatty liver of pregnancy; Reye’s syndrome; acute alcoholic hepatitis Toxins: Amanita phalloides (mushroom ingestion), Bacillus cereus, yellow phosphorus, organic solvents (hydrocarbons, eg carbon tetrachloride) Vascular: ischaemic hepatitis (shock liver); hepatic vein thrombosis (Budd-Chiari syndrome); hepatic veno-occlusive disease; portal vein thrombosis; hepatic artery thrombosis; congestive heart failure; right heart failure Metabolic: α1-antitrypsin deficiency; hereditary fructose intolerance; galactosaemia; LCAT (lecithin-cholesterol acyltransferase) deficiency; Reye’s syndrome; hepatolenticular degeneration; tyrosinaemia Malignancy: primary liver tumours (hepatocellular carcinoma, cholangiocarcinoma); secondary tumours (extensive hepatic metastases from adenocarcinoma, melanoma, lymphoma); leukaemia Miscellaneous: adult-onset Still’s disease; heatstroke Laboratory findings Hepatic injury: elevated transaminases (ALT, AST, GGT) Hepatic dysfunction: coagulopathy not correctable with vitamin K; hypoglycaemia; hypoalbuminaemia; increasing bilirubin; hyperammonaemia; high lactate Hepatic injury: elevated transaminases (ALT, AST, GGT) Hepatic dysfunction: coagulopathy not correctable with vitamin K; hypoglycaemia; hypoalbuminaemia; increasing bilirubin; hyperammonaemia; high lactate

(indicating the need for early endoscopy) Age >50 years with recent onset dyspepsia Anorexia Progressive unintentional weight loss Unexplained iron deficiency anaemia (except in pre-menopausal women) Gastrointestinal bleeding: overt or occult (positive stool occult blood) Progressive dysphagia or odynophagia Persistent or recurrent vomiting Previous gastric ulcer Previous gastric surgery Ulcerogenic medication: NSAID/aspirin/steroid therapy Epigastric mass Epigastric pain severe enough to hospitalise patient Strong history of familial gastrointestinal cancer Concomitant disease with possible gastrointestinal involvement Age >50 years with recent onset dyspepsia Anorexia Progressive unintentional weight loss Unexplained iron deficiency anaemia (except in pre-menopausal women) Gastrointestinal bleeding: overt or occult (positive stool occult blood) Progressive dysphagia or odynophagia Persistent or recurrent vomiting Previous gastric ulcer Previous gastric surgery Ulcerogenic medication: NSAID/aspirin/steroid therapy Epigastric mass Epigastric pain severe enough to hospitalise patient Strong history of familial gastrointestinal cancer Concomitant disease with possible gastrointestinal involvement

Usually originates distal to the duodenojejunal flexure Bright red blood, with or without clots, usually indicates bleeding low in the colon or rectum Dark red or maroon blood usually indicates bleeding higher in the colon or the small bowel Melaena usually indicates bleeding in the stomach Causes of lower gastrointestinal bleeding Small bowel: Diverticular disease: Meckel’s diverticulum; pseudo-diverticula; jejunal diverticula Intusussception Mesenteric infarction Aorto-enteric fistula: primary/ secondary Vascular lesions: angiodysplasia; telangiectasia; arteriovenous malformation Tumours: lymphoma; gastrointestinal stromal tumours; carcinoid; adenocarcinoma Ulceration: Crohn’s disease; Zollinger-Ellison syndrome; NSAIDs, potassium supplements; vasculitis Diverticular disease: Meckel’s diverticulum; pseudo-diverticula; jejunal diverticula Intusussception Mesenteric infarction Aorto-enteric fistula: primary/ secondary Vascular lesions: angiodysplasia; telangiectasia; arteriovenous malformation Tumours: lymphoma; gastrointestinal stromal tumours; carcinoid; adenocarcinoma Ulceration: Crohn’s disease; Zollinger-Ellison syndrome; NSAIDs, potassium supplements; vasculitis Large bowel: Colonic diverticular disease (diverticulosis) Angiodysplasia (vascular ectasias); arteriovenous malformations Colitis Ulcerative proctocolitis Chronic radiation proctocolitis Ischaemic colitis Crohn’s colitis (granulomatous) Carcinoma Hamartomatous and neoplastic polyps Endometriosis Aorto-colonic fistula Colonic diverticular disease (diverticulosis) Angiodysplasia (vascular ectasias); arteriovenous malformations Colitis Ulcerative proctocolitis Chronic radiation proctocolitis Ischaemic colitis Crohn’s colitis (granulomatous) Ulcerative proctocolitis Chronic radiation proctocolitis Ischaemic colitis Crohn’s colitis (granulomatous) Carcinoma Hamartomatous and neoplastic polyps Endometriosis Aorto-colonic fistula Ano-rectal Haemorrhoids; rectal/colonic varices Anal fissure Radiation proctitis Solitary rectal ulcer syndrome Haemorrhoids; rectal/colonic varices Anal fissure Radiation proctitis Solitary rectal ulcer syndrome

Colonic: acute appendicitis; acute enterocolitis; caecal diverticulitis; colonic obstruction; torsion of appendices epiploicae; epiploic appendagitis Small bowel: Crohn’s disease (terminal ileitis); Meckel’s diverticulitis; small bowel obstruction; intusussception (triad of vomiting, abdominal pain and currant jelly stools) Foreign body perforation Mesenteric adenitis Perforated peptic ulcer Gynaecological: ovarian cyst accident (including mittelschmerz)- rupture, torsion; endometriosis; pelvic inflammatory disease(salpingitis); ectopic pregnancy Cholecystitis Vascular: aortic aneurysm: leaking; ruptured; ruptured iliac artery aneurysm Renal: renal/ureteric colic; pyelonephritis Psoas abscess Inguinal hernia: incarcerated; strangulated Testicular torsion Seminal vesiculitis Rectus sheath haematoma Herpes zoster Colonic: acute appendicitis; acute enterocolitis; caecal diverticulitis; colonic obstruction; torsion of appendices epiploicae; epiploic appendagitis Small bowel: Crohn’s disease (terminal ileitis); Meckel’s diverticulitis; small bowel obstruction; intusussception (triad of vomiting, abdominal pain and currant jelly stools) Foreign body perforation Mesenteric adenitis Perforated peptic ulcer Gynaecological: ovarian cyst accident (including mittelschmerz)- rupture, torsion; endometriosis; pelvic inflammatory disease(salpingitis); ectopic pregnancy Cholecystitis Vascular: aortic aneurysm: leaking; ruptured; ruptured iliac artery aneurysm Renal: renal/ureteric colic; pyelonephritis Psoas abscess Inguinal hernia: incarcerated; strangulated Testicular torsion Seminal vesiculitis Rectus sheath haematoma Herpes zoster

Infection: viral: infectious mononucleosis, cytomegalovirus, HIV; bacterial: tuberculosis, infective endocarditis, brucellosis, syphilis, typhoid; fungal: histoplasmosis; parasitic: malaria, visceral leishmaniasis, hydatid disease, schistosomiasis; rickettsial: typhus Congestive splenomegaly due to portal hypertension: cirrhosis (alcoholic liver disease; primary biliary cirrhosis; hepatitis B/C); portal vein thrombosis; splenic vein thrombosis Haematological causes: haemolytic anaemias ; haemoglobinopathies (early sickle cell disease, thalassaemia); haemoglobinopathies; myeloproliferative disorders: chronic leukaemia, acute leukaemia, polycythaemia vera, lymphoma, essential thrombocytosis; extramedullary haematopoiesis: myelofibrosis (agnogenic myeloid metaplasia) Space occupying lesions: cyst; haemangioma Trauma: subcapsular haematoma The 3 Ms of massive splenomegaly are chronic myeloid leukaemia, myelofibrosis, and malaria Infection: viral: infectious mononucleosis, cytomegalovirus, HIV; bacterial: tuberculosis, infective endocarditis, brucellosis, syphilis, typhoid; fungal: histoplasmosis; parasitic: malaria, visceral leishmaniasis, hydatid disease, schistosomiasis; rickettsial: typhus Congestive splenomegaly due to portal hypertension: cirrhosis (alcoholic liver disease; primary biliary cirrhosis; hepatitis B/C); portal vein thrombosis; splenic vein thrombosis Haematological causes: haemolytic anaemias ; haemoglobinopathies (early sickle cell disease, thalassaemia); haemoglobinopathies; myeloproliferative disorders: chronic leukaemia, acute leukaemia, polycythaemia vera, lymphoma, essential thrombocytosis; extramedullary haematopoiesis: myelofibrosis (agnogenic myeloid metaplasia) Space occupying lesions: cyst; haemangioma Trauma: subcapsular haematoma

Age >55 years Pa02 on room air 15,000/cu mm Glucose >10.0 mmol/L Serum calcium <2.0 mmol/L Serum albumin 250 IU/L; lactate dehydrogenase >600 IU/L Serum urea nitrogen >16.1 mmol/L Age >55 years Pa02 on room air 15,000/cu mm Glucose >10.0 mmol/L Serum calcium <2.0 mmol/L Serum albumin 250 IU/L; lactate dehydrogenase >600 IU/L Serum urea nitrogen >16.1 mmol/L

Gallstones Echogenic objects within the echo-free gallbladder lumen Distal acoustic shadowing Mobile, and move with changes in position of the patient: demonstrate gravitational dependency, seeking the most dependent portion of the gallbladder The lumen of the gallbladder may contain lithogenic bile, known as sludge, which has low-level echogenicity (it appears less white than stones), tends to layer out in the dependent portion of the gallbladder with a flat fluid: fluid interface, and fails to shadow. Echogenic objects within the echo-free gallbladder lumen Distal acoustic shadowing Mobile, and move with changes in position of the patient: demonstrate gravitational dependency, seeking the most dependent portion of the gallbladder The lumen of the gallbladder may contain lithogenic bile, known as sludge, which has low-level echogenicity (it appears less white than stones), tends to layer out in the dependent portion of the gallbladder with a flat fluid: fluid interface, and fails to shadow. Acute cholecystitis Symmetrical thickening of the entire gall bladder wall >3 mm Dilated gall bladder: >10 cm in length; >4 cm in width Echo-poor halo around the gallbladder-due to intramural oedema-alternating echogenic and hypo-echoic layers within the wall Gallstones Impacted stone in neck of gallbladder Gas in gallbladder wall The sonographic Murphy sign represents local tenderness and inspiratory arrest over the sonographically visualised gallbladder Increased flow with colour Doppler Peri-cholecystic fluid: focal anechoic collection adjacent to the gallbladder, especially in the region of the fundus; collection >1 cm indicates gallbladder perforation Symmetrical thickening of the entire gall bladder wall >3 mm Dilated gall bladder: >10 cm in length; >4 cm in width Echo-poor halo around the gallbladder-due to intramural oedema-alternating echogenic and hypo-echoic layers within the wall Gallstones Impacted stone in neck of gallbladder Gas in gallbladder wall The sonographic Murphy sign represents local tenderness and inspiratory arrest over the sonographically visualised gallbladder Increased flow with colour Doppler Peri-cholecystic fluid: focal anechoic collection adjacent to the gallbladder, especially in the region of the fundus; collection >1 cm indicates gallbladder perforation

Gastrointestinal bleeding Sepsis; spontaneous bacterial peritonitis Azotemia and hypovolaemia (diuretic-induced) Hypokalaemia; alkalosis CNS depressant drugs: sedatives (benzodiazepines); opiates; tricyclic antidepressant drugs Hepatocellular injury Constipation High protein diet Hypoglycaemia Post-portosystemic shunt placement Gastrointestinal bleeding Sepsis; spontaneous bacterial peritonitis Azotemia and hypovolaemia (diuretic-induced) Hypokalaemia; alkalosis CNS depressant drugs: sedatives (benzodiazepines); opiates; tricyclic antidepressant drugs Hepatocellular injury Constipation High protein diet Hypoglycaemia Post-portosystemic shunt placement

Intra-thoracic: inferior ST elevation myocardial infarction; pericarditis; lower lobe pneumonia; pulmonary embolism; oesophageal disease Endocrine/ metabolic: diabetic ketoacidosis; acute adrenocortical insufficiency; acute intermittent porphyria; hyperlipidaemia; Familial Mediterranean Fever Drug induced: opioid withdrawal; lead poisoning Haematological: sickle cell crisis; acute leukaemia Central nervous system: pre-eruptive phase of herpes zoster; spinal nerve root compression Intra-thoracic: inferior ST elevation myocardial infarction; pericarditis; lower lobe pneumonia; pulmonary embolism; oesophageal disease Endocrine/ metabolic: diabetic ketoacidosis; acute adrenocortical insufficiency; acute intermittent porphyria; hyperlipidaemia; Familial Mediterranean Fever Drug induced: opioid withdrawal; lead poisoning Haematological: sickle cell crisis; acute leukaemia Central nervous system: pre-eruptive phase of herpes zoster; spinal nerve root compression

Difficulty in obtaining a history caused by impaired cognitive function (eg dementia) Atypical presentations Lack of typical clinical findings (eg peritonitis without peritonism) Multiple co-morbidities Medications that block physiological responses leading to difficulty in assessment (eg beta-blockers) Decreased immune function, leading to increased severity of disease Difficulty in obtaining a history caused by impaired cognitive function (eg dementia) Atypical presentations Lack of typical clinical findings (eg peritonitis without peritonism) Multiple co-morbidities Medications that block physiological responses leading to difficulty in assessment (eg beta-blockers) Decreased immune function, leading to increased severity of disease

SYMPTOMS Migration of pain to the right lower quadrant = 1 Anorexia = 1 Nausea or vomiting = 1 Migration of pain to the right lower quadrant = 1 Anorexia = 1 Nausea or vomiting = 1 SIGNS Tenderness in the right lower quadrant = 2 Rebound tenderness = 1 Elevated temperature: fever of 37.3 C or more = 1 Tenderness in the right lower quadrant = 2 Rebound tenderness = 1 Elevated temperature: fever of 37.3 C or more = 1 LABORATORY TESTS Leukocytosis >10,000 white blood cells per microlitre in the serum = 2 Left shift of leukocytes = 1 Leukocytosis >10,000 white blood cells per microlitre in the serum = 2 Left shift of leukocytes = 1 Total = 10 Total = 10 Score 5 or 6: Compatible with the diagnosis of acute appendicitis Score 5 or 6: Compatible with the diagnosis of acute appendicitis 7 or 8: Probable appendicitis 9 or 10: Very probable acute appendicitis 7 or 8: Probable appendicitis 9 or 10: Very probable acute appendicitis

Acute right upper quadrant or loin pain: retro-caecal or retro-colic appendicitis Gastroenteritis: diarrhea and vomiting: pre-and post-ileal appendicitis Acute right lower quadrant pain with psoas irritation Acute small bowel obstruction Dysuria and pyuria; microscopic haematuria: sub-caecal and pelvic appendicitis Acute right upper quadrant or loin pain: retro-caecal or retro-colic appendicitis Gastroenteritis: diarrhea and vomiting: pre-and post-ileal appendicitis Acute right lower quadrant pain with psoas irritation Acute small bowel obstruction Dysuria and pyuria; microscopic haematuria: sub-caecal and pelvic appendicitis

Genetic Polyposis syndromes: familial polyposis coli; Gardner’s syndrome; Turcot syndrome; Oldfield’s syndrome; Peutz-Jeghers syndrome Hereditary non-polyposis syndromes: Lynch syndrome I; Lynch syndrome II Pre-existing disease Inflammatory bowel disease: ulcerative colitis; Crohn’s disease Prior colorectal cancer Adenomatous polyps Pelvic irradiation Breast or genital tract cancer Schistosomiasis General Age of onset of symptoms >40 years Positive family history of colorectal cancer: 1st degree relative with colorectal cancer or adenomatous polyps diagnosed before the age of 60 Genetic Polyposis syndromes: familial polyposis coli; Gardner’s syndrome; Turcot syndrome; Oldfield’s syndrome; Peutz-Jeghers syndrome Hereditary non-polyposis syndromes: Lynch syndrome I; Lynch syndrome II Hereditary non-polyposis syndromes: Lynch syndrome I; Lynch syndrome II Pre-existing disease Inflammatory bowel disease: ulcerative colitis; Crohn’s disease Prior colorectal cancer Adenomatous polyps Pelvic irradiation Breast or genital tract cancer Schistosomiasis General Age of onset of symptoms >40 years Positive family history of colorectal cancer: 1st degree relative with colorectal cancer or adenomatous polyps diagnosed before the age of 60

More than 6 bowel movements per day Temperature >37.8 degrees Centigrade Heart rate >90 beats per minute Haemoglobin 30 mm/hour More than 6 bowel movements per day Temperature >37.8 degrees Centigrade Heart rate >90 beats per minute Haemoglobin 30 mm/hour

Abdominal wall contusion Iliac or pubic fractures Lumbar spine fractures: wedge compression fracture; Chance fracture Intra-abdominal injuries: small bowel perforation; mesenteric tears; bladder rupture Abdominal wall contusion Iliac or pubic fractures Lumbar spine fractures: wedge compression fracture; Chance fracture Intra-abdominal injuries: small bowel perforation; mesenteric tears; bladder rupture

Parietal: irritation of parietal peritoneum Pain in dermatome distribution Well localised Sharp Clear onset Pain in dermatome distribution Well localised Sharp Clear onset Visceral: stretch, distension, contraction (spasm), compression or torsion of a hollow viscus Referred pain in embryonic distribution Poor localisation Dull and aching Insidious onset Referred pain in embryonic distribution Poor localisation Dull and aching Insidious onset Referred

Exogenous blood Epistaxis Uncooked meat Epistaxis Uncooked meat Black stools Iron preparations Grape juice; purple grapes Spinach Chocolate Iron preparations Grape juice; purple grapes Spinach Chocolate Pseudo-blood Medications in red syrup Beets; tomato skin/juice Red diaper syndrome Peach skin; red cherries Cranberry juice Medications in red syrup Beets; tomato skin/juice Red diaper syndrome Peach skin; red cherries Cranberry juice

Gastrointestinal: heartburn; regurgitation; waterbrash; globus sensation of lump in neck or throat; dysphagia (erosive oesophagitis; peptic stricture (intermittent solid food dysphagia in a patient with heartburn); adenocarcinoma of oesophagus); odynophagia; hiccups; epigastric pain, dyspepsia; vomiting; erosion of dental enamel Pulmonary: chronic nocturnal cough; asthma; sleep apnoea; aspiration; recurrent pneumonia; interstitial pulmonary fibrosis; acute life-threatening episodes ENT: sore throat; hoarseness; laryngitis; chronic sinusitis; vocal cord granulomas; sub-glottic stenosis Atypical chest pain Dystonic movements: Sandifer’s syndrome (gastro-oesophageal reflux associated with torsional dystonia of the head, neck, eyes and trunk, and opithostonic posturing) Gastrointestinal: heartburn; regurgitation; waterbrash; globus sensation of lump in neck or throat; dysphagia (erosive oesophagitis; peptic stricture (intermittent solid food dysphagia in a patient with heartburn); adenocarcinoma of oesophagus); odynophagia; hiccups; epigastric pain, dyspepsia; vomiting; erosion of dental enamel Pulmonary: chronic nocturnal cough; asthma; sleep apnoea; aspiration; recurrent pneumonia; interstitial pulmonary fibrosis; acute life-threatening episodes ENT: sore throat; hoarseness; laryngitis; chronic sinusitis; vocal cord granulomas; sub-glottic stenosis Atypical chest pain Dystonic movements: Sandifer’s syndrome (gastro-oesophageal reflux associated with torsional dystonia of the head, neck, eyes and trunk, and opithostonic posturing)

History SOCRATES to characterize pain (allow the patient to describe the pain initially without any leading questions) Site and duration Onset: sudden versus gradual; sudden onset suggests a vascular emergency (mesenteric ischaemia; ruptured abdominal aortic aneurysm), volvulus, intestinal perforation or torsion of hollow viscus Character: sharp, dull, aching, colicky, burning Radiation: shoulder, back, groin or testicle Timing: intermittent, constant Exacerbating (aggravating factors): movement (worsens pain in peritonitis), position, food, medications, and alleviating factors: rest. Severity Site and duration Onset: sudden versus gradual; sudden onset suggests a vascular emergency (mesenteric ischaemia; ruptured abdominal aortic aneurysm), volvulus, intestinal perforation or torsion of hollow viscus Character: sharp, dull, aching, colicky, burning Radiation: shoulder, back, groin or testicle Timing: intermittent, constant Exacerbating (aggravating factors): movement (worsens pain in peritonitis), position, food, medications, and alleviating factors: rest. Severity Associated symptoms: fever; nausea and vomiting; diarrhoea/constipation; haematemesis/ melaena; fresh rectal bleeding; dysuria/ haematuria Physical examination checklist Vital signs; tachypnoea may be related to metabolic acidosis, hypoxaemia, or catecholamine-induced pain response; signs of hypovolaemia: tachycardia, postural hypotension Localisation of maximal tenderness and guarding Signs of peritonitis: tenderness, guarding (abdominal wall rigidity), percussion tenderness, rebound tenderness (gentle depression of the abdominal wall for 15 to 30 minutes, followed by sudden release of pressure), generalised ileus, fever Specific signs: Carnett’s sign: increased pain on tensing abdominal wall when a supine patient lifts the head and shoulders off the bed; Murphy’s sign: inspiratory arrest on deep palpation of right upper quadrant; psoas sign (passive hip extension is painful, with the patient in the lateral decubitus position); Rovsing’s sign (pressure in the left lower quadrant produces rebound pain in the right lower quadrant on release of the pressure); obturator sign (flexion with external and internal rotation of the hip is painful) Abdominal mass Aortic tenderness or enlargement (bedside ultrasound may be useful) Hernial orifices External genitalia Bowel sounds: absent; normal; hyperactive; tinkling Rectal examination Bimanual pelvic examination Vital signs; tachypnoea may be related to metabolic acidosis, hypoxaemia, or catecholamine-induced pain response; signs of hypovolaemia: tachycardia, postural hypotension Localisation of maximal tenderness and guarding Signs of peritonitis: tenderness, guarding (abdominal wall rigidity), percussion tenderness, rebound tenderness (gentle depression of the abdominal wall for 15 to 30 minutes, followed by sudden release of pressure), generalised ileus, fever Specific signs: Carnett’s sign: increased pain on tensing abdominal wall when a supine patient lifts the head and shoulders off the bed; Murphy’s sign: inspiratory arrest on deep palpation of right upper quadrant; psoas sign (passive hip extension is painful, with the patient in the lateral decubitus position); Rovsing’s sign (pressure in the left lower quadrant produces rebound pain in the right lower quadrant on release of the pressure); obturator sign (flexion with external and internal rotation of the hip is painful) Abdominal mass Aortic tenderness or enlargement (bedside ultrasound may be useful) Hernial orifices External genitalia Bowel sounds: absent; normal; hyperactive; tinkling Rectal examination Bimanual pelvic examination

The presence of blood in the stool indicates an invasive infection Volume of stool: large volume watery diarrhea, diffuse abdominal cramps, bloating and borborygmi (bowel sounds audible at a distance) indicate small bowel disease, while small volume bloody diarrhea with lower abdominal cramping and tenesmus (sensation of incomplete bowel evacuation) indicates large bowel disease Travel history Exposure history: exposure to a known source of enteric infection (contaminated food or water)-eating meals out, farm visit; contacts who are ill Ingestion of specific dietary items during food-borne outbreaks: dairy products; eggs; chicken; seafood Recent hospitalization or antimicrobial use: consider Clostridium difficile Risk factors for HIV infection and other co-morbid illnesses resulting in immunosuppression, including cancer chemotherapy, will lead to a wider differential diagnosis The presence of blood in the stool indicates an invasive infection Volume of stool: large volume watery diarrhea, diffuse abdominal cramps, bloating and borborygmi (bowel sounds audible at a distance) indicate small bowel disease, while small volume bloody diarrhea with lower abdominal cramping and tenesmus (sensation of incomplete bowel evacuation) indicates large bowel disease Travel history Exposure history: exposure to a known source of enteric infection (contaminated food or water)-eating meals out, farm visit; contacts who are ill Ingestion of specific dietary items during food-borne outbreaks: dairy products; eggs; chicken; seafood Recent hospitalization or antimicrobial use: consider Clostridium difficile Risk factors for HIV infection and other co-morbid illnesses resulting in immunosuppression, including cancer chemotherapy, will lead to a wider differential diagnosis

A group of symptoms indicative of the presence of upper gastro-intestinal tract disease There are four categories: Ulcer-like: abdominal pain Reflux-like (gastro-oesophageal reflux): heartburn; regurgitation; retrosternal discomfort Dysmotility-like (delayed gastric emptying): early satiety; post-prandial fullness and bloating Non-specific or unspecified Ulcer-like: abdominal pain Reflux-like (gastro-oesophageal reflux): heartburn; regurgitation; retrosternal discomfort Dysmotility-like (delayed gastric emptying): early satiety; post-prandial fullness and bloating Non-specific or unspecified

All: FBC, U&E, LFTs, bone profile, CXR (mediastinal widening, absence of gastric air bubble, extrinsic mass) Oropharyngeal: direct laryngoscopy; video fluoroscopy Oesophageal: endoscopy; barium swallow; oesophageal manometry All: FBC, U&E, LFTs, bone profile, CXR (mediastinal widening, absence of gastric air bubble, extrinsic mass) Oropharyngeal: direct laryngoscopy; video fluoroscopy Oesophageal: endoscopy; barium swallow; oesophageal manometry

Solid viscus: liver, spleen, kidneys, pancreas Hollow viscus: small intestine; large intestine; stomach; oesophagus; urinary bladder Vascular injuries: aorta; inferior vena cava Bones: pelvis; lumbar spine Diaphragm Solid viscus: liver, spleen, kidneys, pancreas Hollow viscus: small intestine; large intestine; stomach; oesophagus; urinary bladder Vascular injuries: aorta; inferior vena cava Bones: pelvis; lumbar spine Diaphragm

Abdominal pain: Ischaemic bowel: ischaemic colitis Inflammatory bowel disease: Crohn’s disease; ulcerative colitis Ruptured abdominal aortic aneurysm Ischaemic bowel: ischaemic colitis Inflammatory bowel disease: Crohn’s disease; ulcerative colitis Ruptured abdominal aortic aneurysm Painless bleeding: Diverticuli (diverticular disease) Angiodysplasia Polyps Haemorrhoids Diverticuli (diverticular disease) Angiodysplasia Polyps Haemorrhoids Bloody diarrhoea: Inflammatory bowel disease Infection: infectious colitis (E coli O157: H7; Shigella; Salmonella; Campylobacter jejuni) Inflammatory bowel disease Infection: infectious colitis (E coli O157: H7; Shigella; Salmonella; Campylobacter jejuni) Rectal pain: Anal fissure Haemorrhoids Anal fissure Haemorrhoids Constipation: Colorectal malignancy Haemorrhoids Colorectal malignancy Haemorrhoids

Organ Site of pain Dermatomes Stomach Epigastrium T6-T10 Small bowel Umbilical T9-T10 Gallbladder Epigastrium T7-T9 Pancreas Epigastrium T6-T10 Colon up to splenic flexure Umbilical T11-L1 Colon from splenic flexure Hypogastrium L1-L2 Testis and ovary Umbilical T10-T11

Digital rectal examination Full blood count Serum calcium Thyroid function tests Digital rectal examination Full blood count Serum calcium Thyroid function tests

Osmotic (high osmotic load of intraluminal content) Lactase deficiency Disaccharidase deficiencies Magnesium induced Short bowel Extensive mucosal disease: celiac disease; Crohn’s disease Bile salt malabsorption Pancreatic insufficiency Drugs, eg lactulose Lactase deficiency Disaccharidase deficiencies Magnesium induced Short bowel Extensive mucosal disease: celiac disease; Crohn’s disease Bile salt malabsorption Pancreatic insufficiency Drugs, eg lactulose Secretory (active chloride secretion) Toxins: cholera; clostridium Excess gut hormones Stimulant laxatives Bacterial overgrowth Inflammatory bowel disease Diabetic neuropathy Villous adenoma of the rectum Carcinoma of the rectum Neural crest tumours, eg carcinoid, VIPoma Toxins: cholera; clostridium Excess gut hormones Stimulant laxatives Bacterial overgrowth Inflammatory bowel disease Diabetic neuropathy Villous adenoma of the rectum Carcinoma of the rectum Neural crest tumours, eg carcinoid, VIPoma Dysmotility Functional bowel disease Endocrine disorders Autonomic neuropathies Functional bowel disease Endocrine disorders Autonomic neuropathies Inflammatory Infections Inflammatory bowel disease Ischaemic bowel disease Infections Inflammatory bowel disease Ischaemic bowel disease

Hypovolaemic shock Evidence of intraperitoneal penetration: signs of peritonism (guarding, rebound tenderness); free intraperitoneal air; omental evisceration; implement in situ Gastrointestinal bleeding Seat belt marks Steering wheel contusion Bicycle handlebar marks on the upper abdomen Macroscopic haematuria Flank (Grey Turner) or peri-umbilical (Cullen) ecchymosis Abdominal bruit Hypovolaemic shock Evidence of intraperitoneal penetration: signs of peritonism (guarding, rebound tenderness); free intraperitoneal air; omental evisceration; implement in situ Gastrointestinal bleeding Seat belt marks Steering wheel contusion Bicycle handlebar marks on the upper abdomen Macroscopic haematuria Flank (Grey Turner) or peri-umbilical (Cullen) ecchymosis Abdominal bruit Confounding factors in the evaluation of abdominal trauma Head injury with altered level of consciousness Alcohol/drug intoxication Spinal cord injury Distracting injury Head injury with altered level of consciousness Alcohol/drug intoxication Spinal cord injury Distracting injury

Peri-stomal wound infection: cellulitis (pain, redness, induration), discharge, fluctuant mass at the site; may progress to necrotising fasciitis, peritonitis, deep wound abscess Buried bumper syndrome (internal bumper buried within gastric mucosa): peri-stomal leakage/infection; immobile catheter; abdominal pain and flow resistance on attempted flushing Inadvertent removal: if the PEG tube has been in situ for more than 1 month, a mature tract may be assumed to be present Gastric outlet obstruction: intermittent vomiting, cramping abdominal pain; aspiration pneumonia Peri-stomal wound infection: cellulitis (pain, redness, induration), discharge, fluctuant mass at the site; may progress to necrotising fasciitis, peritonitis, deep wound abscess Buried bumper syndrome (internal bumper buried within gastric mucosa): peri-stomal leakage/infection; immobile catheter; abdominal pain and flow resistance on attempted flushing Inadvertent removal: if the PEG tube has been in situ for more than 1 month, a mature tract may be assumed to be present Gastric outlet obstruction: intermittent vomiting, cramping abdominal pain; aspiration pneumonia

Dilated peripheral colonic loops (>6 cm, except in caecum, where >9 cm is abnormal dilatation) Collapsed distal colon Small bowel dilatation depends on the competence of the ileocaecal valve Incomplete haustral markings Dilated peripheral colonic loops (>6 cm, except in caecum, where >9 cm is abnormal dilatation) Collapsed distal colon Small bowel dilatation depends on the competence of the ileocaecal valve Incomplete haustral markings

Persistent or recurrent rectal bleeding, especially with onset aged over 40 years Altered bowel habit Tenesmus Atypical presentations: “piles”; anal pain from anoderm involvement; secondary deposits: chest; liver Local complications Perforation: local abscess; generalised peritonitis Intestinal obstruction Abscess: sacral/perineal pain Fistula: bladder (male); vagina (female) Persistent or recurrent rectal bleeding, especially with onset aged over 40 years Altered bowel habit Tenesmus Atypical presentations: “piles”; anal pain from anoderm involvement; secondary deposits: chest; liver Local complications Perforation: local abscess; generalised peritonitis Intestinal obstruction Abscess: sacral/perineal pain Fistula: bladder (male); vagina (female) Local complications Perforation: local abscess; generalised peritonitis Intestinal obstruction Abscess: sacral/perineal pain Fistula: bladder (male); vagina (female)

Not unique to pregnancy Viral hepatitis Budd-Chiari syndrome Hepatic malignancy Biliary colic Choledocholithiasis Cholangitis Cholecystitis Viral hepatitis Budd-Chiari syndrome Hepatic malignancy Biliary colic Choledocholithiasis Cholangitis Cholecystitis Unique to, or highly associated with, pregnancy Pre-eclampsia or eclampsia HELLP (haemolysis, elevated liver enzymes and low platelet count) syndrome (third trimester) Acute fatty liver of pregnancy Hepatic haemorrhage or rupture Symptomatic choledochal cysts Pre-eclampsia or eclampsia HELLP (haemolysis, elevated liver enzymes and low platelet count) syndrome (third trimester) Acute fatty liver of pregnancy Hepatic haemorrhage or rupture Symptomatic choledochal cysts

Venous blood: full blood count, urea and electrolytes, CRP, liver function tests (right upper quadrant pain), amylase/lipase, glucose; blood gas analysis 12 lead ECG Ultrasound/CT Urine dipstick Urine beta-HCG (all women of child bearing age) Venous blood: full blood count, urea and electrolytes, CRP, liver function tests (right upper quadrant pain), amylase/lipase, glucose; blood gas analysis 12 lead ECG Ultrasound/CT Urine dipstick Urine beta-HCG (all women of child bearing age)