Symptom Sorter

SIXTH EDITION
Symptom Sorter
SIXTH EDITION

Keith Hopcroft
General Practitioner
Laindon Health Centre
Basildon, Essex

and
Vincent Forte
Former General Practitioner
Gorleston, Norfolk
Sixth edition published 2020

by CRC Press
6000 Broken Sound Parkway NW, Suite 300, Boca Raton, FL 33487-2742

and by CRC Press

2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN

© 2020 Keith Hopcroft and Vincent Forte

CRC Press is an imprint of Taylor & Francis Group, LLC

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Library of Congress Cataloging-in-Publication Data

Names: Hopcroft, Keith, author. | Forte, Vincent (General practitioner), author.

Title: Symptom sorter / Keith Hopcroft and Vincent Forte.
Description: Sixth edition. | Boca Raton : CRC Press/Taylor & Francis Group, [2020] |
Includes bibliographical references and index.
Identifiers: LCCN 2019056048 | ISBN 9780367468095 (paperback) |
ISBN 9780367468101 (hardback) | ISBN 9781003032106 (ebook)
Subjects: MESH: Signs and Symptoms | Diagnosis | Diagnosis, Differential |
Diagnostic Techniques and Procedures | Handbook
Classification: LCC RC69 | NLM WB 39 | DDC 616/.047--dc23
LC record available at [Link]

ISBN: 9780367468101 (hbk)

ISBN: 9780367468095 (pbk)
ISBN: 9781003032106 (ebk)
Typeset in Garamond Premr Pro
by Nova Techset Private Limited, Bengaluru & Chennai, India
 To Ali D, my rock
—VF

To D, H and W: Thank you for sorting out all the symptoms

I developed writing this book
—KH
CONTENTS
Abbreviations ix

Introduction 1

Abdomen 5

Anorectal 49

Breast 65

Cerebral 79

Chest 105

Ear127

Eye141

Face163

General physical 177

Genital 243

Hair and Nails 275

Limbs 287

Neck 331

Nose 349

Oral359

Pelvic 375

Periods 385

Skin399

Urinary 425

Index 447

vii
ABBREVIATIONS
A&E accident and emergency CT computed tomography
ABPI ankle brachial pressure index CVA cerebrovascular accident
ACE angiotensin-converting enzyme CXR chest X-ray
ACR albumin creatinine ratio D&C dilatation and curettage
ACTH adrenocorticotrophic hormone DIC disseminated intravascular
ADH antidiuretic hormone coagulation
AF atrial fibrillation DKA diabetic ketoacidosis
AFP α fetoprotein DM diabetes mellitus
ALT alanine-amino transferase DU duodenal ulcer
anti-CCP anti-cyclic citrullinated peptide DUB dysfunctional uterine bleeding
ANUG acute necrotising ulcerative DVT deep vein thrombosis
gingivitis DXA dual energy X-ray
ARC AIDS-related complex absorptiometry
ASO antistreptolysin EAM external auditory meatus
AST aspartate-amino transferase EBV Epstein–Barr virus
BCC basal cell carcinoma ECG electrocardiogram
BNP B type natriuretic peptide EEG electroencephalogram
BP blood pressure ELISA enzyme-linked immunosorbent
BPH benign prostatic hypertrophy assay
BTB breakthrough bleeding EMG electromyography
BV bacterial vaginosis EMU early morning urine (sample)
BXO balanitis xerotica obliterans ENT ear, nose and throat
CA-125 cancer antigen 125 EO epididymo-orchitis
CCF congestive cardiac failure ERCP endoscopic retrograde
CKD chronic kidney disease cholangiopancreaticogram
CMPI cow’s milk protein intolerance ESR erythrocyte sedimentation rate
CNS central nervous system ET Eustachian tube
COPD chronic obstructive pulmonary FBC full blood count
disease FIT faecal immunochemical test
CPK creatine phosphokinase FSH follicle-stimulating hormone
CREST calcinosis/Raynaud’s γGT gamma glutamyl transpeptidase
phenomenon/oesophagealdys​ GAD generalised anxiety disorder
motility/sclerodactyly/ GF glandular fever
telangiectasia GI gastrointestinal
CRP C-reactive protein GI granuloma inguinale
CSF cerebrospinal fluid GnRH gonadotrophin-releasing
CT carpal tunnel hormone

ix
 x Abbreviations

GORD gastro-oesophageal reflux NSAID non-steroidal anti-inflammatory

disease drug
GUM genito-urinary medicine OA osteoarthritis
Hb haemoglobin OE otitis externa
HCG human chorionic gonadotrophin O/E on examination
5HIAA 5-hydroxy-indole-acetic acid OG onychogryphosis
HIV human immunodeficiency virus OGD oesophago-gastro duodenoscopy
HLA human leucocyte antigen OM otitis media
HRT hormone-replacement therapy OTC over the counter
HSV herpes simplex virus PAN polyarteritis nodosa
HVS high vaginal swab PCOS polycystic ovary syndrome
IBD inflammatory bowel disease PCR protein creatinine ratio
IBS irritable bowel syndrome PCV packed cell volume
IC intermittent claudication PE pulmonary embolism
IGTN ingrowing toenail PEFR peak expiratory flow rate
IHD ischaemic heart disease PF proctalgia fugax
INR international normalised ratio PID pelvic inflammatory disease
ITP idiopathic thrombocytopenia PMR polymyalgia rheumatica
purpura PMT pre-menstrual tension
IUCD intrauterine contraceptive PR per rectum
device PRIST paper radioimmunosorbent disc
IVP intravenous pyelogram test
IVU intravenous urogram PSA prostate-specific antigen
JCA juvenile chronic arthritis PTH parathyroid hormone
LFT liver function tests PU peptic ulcer
LGV lymphogranuloma venereum PUO pyrexia of unknown origin
LH luteinising hormone PV per vagina
LMP last menstrual period PVE per vaginal examination
LN lymph node PVD peripheral vascular disease
LRTI lower respiratory tract infection RA rheumatoid arthritis
LSD lysergic acid diethylamide RAST radioallergosorbent test
LUTS lower urinary tract symptoms RAU recurrent aphthous ulceration
LVF left ventricular failure RLS restless legs syndrome
MAOI monoamine oxidase inhibitor RUQ right upper quadrant
MC&S microscopy, culture and SA septic arthritis
sensitivity SCC squamous cell carcinoma
MCV mean cell volume SHBG serum hormone binding
MI myocardial infarction globulin
MMR measles, mumps, rubella SLE systemic lupus erythematosus
MRI magnetic resonance imaging SOB shortness of breath
MS multiple sclerosis STD sexually transmitted disease
MSU mid-stream urine (sample) SVT supraventricular tachycardia
NAI non-accidental injury TAH total abdominal hysterectomy
NICE National Institute for Health TATT ‘tired all the time’
and Care Excellence TB tuberculosis
 Abbreviations xi

TCA tricyclic antidepressant U&E urea and electrolytes

TFT thyroid function tests URTI upper respiratory tract infection
TIA transient ischaemic attack UTI urinary tract infection
TMJ temporomandibular joint UV ultraviolet
TN trigeminal neuralgia VMA vanillyl-mandelic acid
TSH thyroid-stimulating hormone VT ventricular tachycardia
TURP transurethral resection of WCC white cell count
prostate WRULD work-related upper limb
TV trichomonal vaginosis disorder
INTRODUCTION
Life would be much simpler for GPs if patients presented with diagnoses. Unfortunately, they
do not: they present with symptoms, which are frequently vague, sometimes multiple and
occasionally obscure. It is up to the GP to create some order from this chaos. However, the vast
majority of clinical texts adopt a diagnosis, rather than symptom-based, approach, and the few
which do reflect the reality of patient presentations are inevitably orientated towards hospital
medicine and so are irrelevant to GPs.
This book aims to redress the balance. It analyses a multitude of symptoms commonly seen in
primary care and, for each, presents differentials, distinguishing features, possible investigations
and key points. The only omissions are presentations for which there are so few differentials that
diagnosis is really quite simple (e.g. ‘lump on elbow’); those which rarely present in isolation (e.g.
nausea, anorexia); and those which are so rare that the reader would be sure to require specialist
advice (our personal favourite being ‘pilimiction’).
Written by two full-time GP principals, its perspective is very much grass roots primary
care – though informed by the latest evidence and guidance where possible or appropriate –
and its appeal is therefore wide. GP registrars and young principals, relatively unfamiliar with
the protean presentations possible in general practice, will be able to check their diagnostic
hypotheses against the information in the book; the more experienced GP might use it as a
refresher or as a pointer to a more exotic diagnosis in an unusual case; and the nurse practitioner,
taking increasing responsibility as a first port of call in primary care for many patients, will find
the contents unique and essential.
The popularity of the first edition and the need for multiple subsequent editions emphasises
the fact that, while general practice may experience many reorganisations and restructurings,
the bread and butter business of making sense of symptoms remains. This new edition adds a
number of extra chapters and significant updates of existing chapters.
Each symptom is analysed in a uniform, accessible way, as follows.

The GP overview
This defines the symptom and its key characteristics, and gives some idea of the frequency of
presentation.

Differential diagnosis
This lists the likely diagnoses, subdivided ‘Common’, ‘Occasional’ and ‘Rare’. (It should be
noted that these headings are relative to the symptom in question.) Restrictions of space and

1
 2 Symptom Sorter

imagination mean that such a differential can never claim to be exhaustive, and a lack of accurate
prevalence data renders the allocation of the diagnoses to these subdivisions somewhat arbitrary,
based on our experience rather than hard evidence. These are minor limitations, however; this
section will invariably provide clear guidance as to the likely cause of any symptom.

Ready reckoner
This provides a quick guide to the key distinguishing features of the five most likely diagnoses
listed in the preceding section.

Possible investigations
This section outlines those investigations likely to assist the reader in making a diagnosis.
The emphasis is upon tests performed in primary care or usually arranged by the GP. Where
appropriate, more complex, hospital-initiated investigations are outlined – partly because
GPs may wish to let their patients know the type of tests they might anticipate after referral
and also because GP access to traditionally hospital-organised investigation is increasing. All
investigations discussed are categorised according to the likelihood that they will be performed,
the three categories being, ‘Likely’, ‘Possible’ and ‘Small print’.

TOP TIPS
This provides a potpourri of management nuggets appropriate to each symptom, which the
authors have accumulated over the years. Such hints from experience are difficult to analyse
or quantify and so most are unashamedly anecdotal rather than evidence based – this should
not detract from their usefulness or occasional elegance. Some might appear to stretch the
scope of the book in that they cross the boundary between symptom assessment and symptom
management – but the reader should bear in mind that the diagnostic process, particularly in
primary care, involves hypothesis testing, and so these boundaries are, in reality, blurred.

Most symptoms presented in primary care are benign, minor and self-limiting. This can
occasionally lull the unwary into a false sense of security: for each presentation there exist
pointers which should set alarm bells ringing. ‘Red flags’ highlight aspects of symptoms which
suggest significant pathology and which therefore should not be missed or neglected.
 Introduction 3

How to use this book

This Symptom Sorter is designed to act as a rapid reference. It has deliberately been written in
a note and list format so that, unlike weightier tomes, it is quick and easy to use. For the sake
of brevity, common and well-recognised abbreviations have been used whenever possible. Its
consistent style will soon breed familiarity and allow the reader to know where and how to
retrieve information painlessly. To help achieve this, the symptoms are arranged in sections,
each section corresponding to a system or anatomical region. In these sections, the symptoms
are arranged alphabetically and, for the most part, are labelled in patient, rather than doctor,
vernacular (e.g. shortness of breath rather than dyspnoea) – the exceptions being where there is
no acceptable or concise ‘patientspeak’ version. However, as many symptoms can have a variety of
descriptions (e.g. shortness of breath, dyspnoea, breathlessness, wheeziness, difficulty breathing
and so on) the index is deliberately expansive and cross-referenced, and will quickly guide the
reader to the appropriate pages.
The categorisation of symptoms and their arrangement in sections is a complex task which
can be approached in a number of ways – for example, rashes might be divided according
to distribution, size of lesion, morphology, itch and so on. Throughout, we have chosen the
approach which seems most logical to us and which, whenever possible, avoids unnecessary
omission or repetition; again, the index should rapidly point the reader in the right direction.
Assigning symptoms to certain sections may sometimes seem arbitrary, especially when they
can have such disparate causes, but this approach provides the book with a clear, understandable
structure.
As GPs, we are aware that patients often present polysymptomatically. Our book, neatly
dividing complaints into individual symptoms, might therefore be criticised for not accurately
reflecting real primary care life. In fact, such presentations can usually be distilled down to
one or two predominant symptoms; more minor symptoms often act as pointers to the actual
diagnosis, a fact our ‘Ready reckoners’ in each chapter exploits. In the truly polysymptomatic,
the book may help to define a common thread among the symptoms, thereby revealing the real
diagnosis – usually, in such cases, anxiety or depression.
The book should be kept to hand for use during surgery to confirm the likelihood of a certain
diagnosis or raise the possibility of others. Being comprehensive, relevant and accessible, retrieval
of information will be speedy and helpful during the consultation itself (you may wish to wait
until the patient is undressing behind the curtain: there should be time).
The book may be used in other ways. GP trainers could use the analysis of a certain symptom
provided in the text as the basis for a tutorial. Indeed, the book could itself form part of the
GP registrar’s curriculum. By ‘sorting’ two or three symptoms a week, using the text as a guide,
the registrar could, over the course of his or her time in practice, cover the vast majority of
presentations seen in primary care. Trainers of undergraduates, too, will find that the contents
provide useful material for teaching sessions.
Others might simply like to browse, refreshing or refining their diagnostic skills and mulling
over the ‘Red flags’ and ‘Top tips’.
 4 Symptom Sorter

Feedback received by the authors indicates that previous editions are now included in many
undergraduate curricula as recommended reading, and the book is proving very popular among
primary care nurses and nurse practitioners.
However the reader uses this book, we are convinced that it will prove an essential resource.
Making sense of symptoms is the essence of general practice, and any tool designed by and for
GPs which contributes to this art is likely to benefit doctors and patients alike.

Keith Hopcroft
Vincent Forte
October 2019
 ABDOMEN
Abdominal swelling 6

Acute abdominal pain in adults 9

Acute abdominal pain in children 12

Acute abdominal pain in pregnancy 15

Chronic/recurrent abdominal pain in adults 18

Constipation21

Diarrhoea in adults 24

Diarrhoea in children 27

Epigastric pain 30

Loin pain 33

Recurrent childhood abdominal pain 36

Vomiting39

Vomiting blood 42

Vomiting in infants 45

For ‘Difficulty swallowing’, see ‘Neck’ chapter

5
ABDOMINAL SWELLING

The GP overview
This presentation covers both abdominal and pelvic masses, and general abdominal swelling. The
patient may complain of a general increase in girth or of a discrete mass discovered accidentally;
alternatively the GP might find the swelling while performing a physical examination.

Differential diagnosis
COMMON
◩◩ pregnancy
◩◩ irritable bowel syndrome (IBS)
◩◩ constipation
◩◩ fibroid uterus
◩◩ enlarged bladder

OCCASIONAL
◩◩ coeliac disease
◩◩ ascites (itself has many causes)
◩◩ intestinal obstruction
◩◩ ovarian mass (cyst or malignant tumour)
◩◩ carcinoma of stomach or colon
◩◩ hepatomegaly (various causes)

RARE
◩◩ splenomegaly (various causes)
◩◩ pancreatic carcinoma
◩◩ aortic aneurysm
◩◩ massive para-aortic lymphadenopathy
◩◩ hydronephrosis, renal cysts and renal malignancy

6
 Abdominal swelling 7

Ready reckoner
Pregnancy IBS Constipation Fibroid uterus Bladder
Size varies No Yes Possible No Possible
Amenorrhoea Yes No No No No
Poor urinary stream No No No No Yes
Diarrhoea No Yes Possible No No
Cannot get below Yes No Possible Yes Yes

Possible investigations
LIKELY: Pregnancy test, ultrasound.
POSSIBLE:Urinalysis, FBC, U&E, LFT, CA-125, anti-endomysial and anti-gliadin antibodies,
plain abdomen X-ray.
SMALL PRINT: Hospital-based lower GI investigations, paracentesis, CT scan.

◩◩ Pregnancy test essential in amenorrhoeic women.

◩◩ Urinalysis may reveal microscopic haematuria in renal or bladder tumours.
◩◩ Abdominal ultrasound is the quickest and most efficient way to define the source of most
abdominal swellings or masses. Ultrasound of pelvis/abdomen may also be indicated
according to an elevated CA-125 (see below).
◩◩ Full blood count (FBC): Anaemia likely in malignancy, possible in fibroids with menorrhagia;
also will reveal blood dyscrasias.
◩◩ Urea and electrolytes (U&E) may be deranged in gross renal disease. Liver function tests
(LFTs) may give a clue to alcoholic hepatomegaly or malignancy. Low albumin in ascites.
◩◩ CA-125: May be indicated in women, especially those aged 50 or more, to help exclude
ovarian cancer.
◩◩ Anti-endomysial and anti-gliadin antibodies: For possible coeliac disease.
◩◩ Hospital-based lower GI investigations: Useful to confirm or exclude colonic disease.
◩◩ Plain abdominal X-ray: May show constipation or obstruction (in the latter case, likely to be
arranged after admission).
◩◩ Other tests are likely to be arranged after specialist referral, e.g. paracentesis (to investigate
and relieve ascites), CT scanning (to establish nature of mass and its effects on surrounding
structures).

TOP TIPS
◩◩ Take care in the history to distinguish between intermittent or variable swelling, and
progressive swelling. The former will probably not be caused by serious pathology, whereas
the latter may well be.
◩◩ Pregnancy can catch out the unwary, particularly when dealing with perimenopausal women
or teenage girls. Do not accept the claim that ‘I can’t be pregnant’.
 8 Symptom Sorter

◩◩ Some ‘swellings’ turn out, on examination, to be impalpable or to represent normal anatomy.

The physical examination may have a therapeutic effect. If not, explore the patient’s concerns
more fully and consider anxiety, depression or other psychological problems if symptoms
persist.

◩◩ Weight loss in conjunction with abdominal swelling should immediately suggest malignancy.
◩◩ Acute onset of swelling with abdominal pain suggests obstruction, requiring urgent surgical
attention.
◩◩ Obesity presents difficulties in examination and can be difficult to distinguish from ascites.
If in doubt, arrange an ultrasound.
◩◩ Resonance on percussion does not rule out a solid mass: Retroperitoneal masses will push
bowel anteriorly and may be apparently tympanic.

NOTES:
ACUTE ABDOMINAL
PAIN IN ADULTS

The GP overview
The sudden onset of severe abdominal pain represents a genuine emergency in general practice
and is a common out-of-hours call. In the true acute abdomen, the patient is obviously ill, and
as the clinical condition may deteriorate rapidly, ensure that you examine the patient as soon
as possible.
NOTE: Upper and mid-abdominal pain are dealt with here. Lower abdominal pain is dealt with
under ‘acute pelvic pain’ and specifically epigastric-type pain is covered in more detail in the
epigastric pain section.

Differential diagnosis
COMMON
◩◩ peptic ulcer
◩◩ biliary colic
◩◩ appendicitis
◩◩ gastroenteritis
◩◩ renal colic

OCCASIONAL
◩◩ cholecystitis (may follow biliary colic, but pain is constant and fever present)
◩◩ diverticulitis
◩◩ acute or subacute bowel obstruction (adhesions, carcinoma, strangulated hernia, volvulus)
◩◩ pyelonephritis
◩◩ muscular wall pain
◩◩ pancreatitis
◩◩ Meckel’s diverticulum

RARE
◩◩ perforation (e.g. duodenal ulcer [DU], carcinoma) resulting in peritonitis
◩◩ hepatitis
◩◩ Crohn’s and ulcerative colitis
◩◩ ischaemic bowel

9
 10 Symptom Sorter

◩◩ dissecting/leaking aneurysm
◩◩ diabetic ketoacidosis (DKA) and other occasional medical causes (e.g. myocardial infarction
[MI], pneumonia, sickle cell crisis)

Ready reckoner
Peptic ulcer Renal colic Biliary colic Appendicitis Gastroenteritis
Colicky pain No Yes Yes No Yes
Localised pain Yes Yes Yes Yes No
Abdominal tenderness Yes No Possible Yes Possible
Fever No No No Yes Possible
Diarrhoea No No No Possible Yes

Possible investigations
The only test likely to help the GP is urinalysis: This may reveal haematuria (renal colic), evidence
of urinary infection or glycosuria in DKA. In general, the following investigations will be done
in hospital after acute admission.
◩◩ Full blood count: WCC raised in many causes and confirms acute inflammation or infection.
◩◩ U&E essential as abnormalities common with diarrhoea or vomiting. Amylase raised in
ischaemic bowel and acute pancreatitis.
◩◩ LFT may show raised bilirubin in biliary obstruction, and widespread derangement in
hepatitis.
◩◩ Helicobacter pylori testing: Strong association with peptic ulcer disease.
◩◩ Upper GI endoscopy: To visualise upper GI tract.
◩◩ Plain erect abdominal X-ray invaluable to confirm perforated viscus (air under diaphragm).
Supine also necessary if obstruction suspected. Ninety percent of renal or ureteric stones will
be revealed with a plain abdominal X-ray.
◩◩ Ultrasound: Helpful to confirm gallstones.
◩◩ Renal imaging: For ureteric stones.

TOP TIPS
◩◩ The aim of assessment is correct disposal rather than an exact diagnosis. Colicky pain may
be appropriate to manage at home; constant pain with tenderness is likely to need admission.
◩◩ If treating a patient at home, arrange for review as appropriate and ensure that the patient is
aware of the symptoms which should prompt urgent reassessment.
◩◩ The examination is likely to contribute significantly to making the diagnosis – so take
particular care and don’t forget the basics such as pulse rate, temperature, bowel sounds and
a rectal examination.
 Acute abdominal pain in adults 11

◩◩ Beware ‘gastroenteritis’ masking or developing into an acute appendicitis. Make arrangements

for follow-up and emphasise that constant pain needs urgent review.
◩◩ Prejudice is easy if the patient has a history of functional problems or irritable bowel. Surgical
pathology can happen to anyone, so be objective.
◩◩ Beware the elderly patient with an irregular pulse: Mesenteric infarction causes severe pain
but few signs.
◩◩ Don’t forget to examine the hernial orifices, especially if obstruction is a possibility.

NOTES:
ACUTE ABDOMINAL
PAIN IN CHILDREN

The GP overview
This causes significant worry in parents, often about the possibility of appendicitis. Some of the
causes listed here (such as infant colic and constipation) can cause recurrent or chronic pain –
this is a less common presentation, but one which, in children, still has a tendency to be presented
as an ‘acute’ problem, either because of a perceived deterioration or parental anxiety. For more
details about recurrent childhood abdominal pain, see the section of the same name.

Differential diagnosis
COMMON
◩◩ constipation
◩◩ infant colic
◩◩ gastroenteritis
◩◩ urinary tract infection
◩◩ appendicitis

OCCASIONAL
◩◩ functional/IBS
◩◩ stress/malingering (e.g. school problems, bullying)
◩◩ gastritis/GORD/peptic ulcer
◩◩ mesenteric adenitis
◩◩ CMPI
◩◩ muscular strain

RARE
◩◩ inflammatory bowel disease
◩◩ pneumonia
◩◩ Meckel’s diverticulum
◩◩ intussusception
◩◩ coeliac disease
◩◩ intestinal obstruction
◩◩ testicular torsion
◩◩ Henoch–Schönlein purpura

12
 Acute abdominal pain in children 13

◩◩ sickle cell crises

◩◩ lead poisoning/porphyria
◩◩ renal causes (stones, hydronephrosis)
◩◩ diabetic ketoacidosis

Ready reckoner
Constipation Infant colic Gastroenteritis UTI Appendicitis
Child under 6 months Possible Yes Possible Possible Possible
Recurrent Possible Yes No Possible No
Child acutely unwell No No Possible Possible Yes
Pain constant No No No No Yes
Urinary symptoms Possible No No Yes No

Investigations
LIKELY: Urinalysis, MSU.
POSSIBLE: FBC, ESR/CRP, U&E, abdominal ultrasound.
SMALL PRINT: Coeliac screen, haemoglobinopathy screen.

◩◩ Urinalysis: Positive nitrite, leucocytes and/or blood support a clinical diagnosis of UTI;
blood alone may indicate a stone (rare); urinalysis will also reveal sugar and ketones in
diabetic ketoacidosis.
◩◩ FBC: May be iron deficiency in IBD.
◩◩ U&E: May occasionally be deranged in renal cause.
◩◩ Abdominal ultrasound: If renal causes suspected.
◩◩ Coeliac screen: Anti-endomysial and anti-gliadin antibodies suggest coeliac disease.
◩◩ Haemoglobinopathy screen: If sickle cell suspected.

TOP TIPS
◩◩ Be clear about safety netting – appendicitis may mimic gastroenteritis in the early stages.
Share doubt and emphasise the need for reassessment if the pain becomes worse and constant,
or if the general condition of the child deteriorates.
◩◩ Don’t forget to examine the groin and testicles – strangulated hernias and torted testicles
are possible causes of this presentation, and the child may be too embarrassed to indicate the
site of pain or swelling.
◩◩ Young children with less significant causes have a tendency to indicate the umbilicus as
the site of pain. The further from the umbilicus the pain, the more you should consider an
important cause.
◩◩ Recurrent ‘acute’ abdominal pain presenting on Mondays may indicate a school problem.
 14 Symptom Sorter

◩◩ Constant pain and the child being unable to straighten up because of discomfort suggest a
surgical cause.
◩◩ Remember the possibility of sickling in the appropriate ethnic groups.
◩◩ Bear in mind that young children with pneumonia can present with abdominal pain – if
unclear about the cause in an unwell child, check vital signs, features of respiratory distress
and chest sounds.
◩◩ Consider intussusception in the infant with apparent abdominal pain associated with bouts
of screaming and pallor.

NOTES:
ACUTE ABDOMINAL
PAIN IN PREGNANCY

The GP overview
A pregnant woman who develops this symptom is very likely to be extremely concerned that
there is a threat to her pregnancy. Anxiety levels may therefore be high in the patient and her
partner. Acknowledge this emotional distress by an urgent and full assessment. Listed here are
causes specific to pregnancy and conditions which may be exacerbated or altered by pregnancy;
‘run of the mill’ causes (such as gastroenteritis, IBS and dyspepsia) may obviously occur too, but
rarely create diagnostic problems and so are not considered in this section.

Differential diagnosis
COMMON
◩◩ symphysis pubis and ligament strain
◩◩ miscarriage: 20%–40% of pregnancies in first trimester
◩◩ labour: 6% premature
◩◩ placental abruption: 1/80–200 pregnancies
◩◩ pyelonephritis (especially around 20 weeks)

OCCASIONAL
◩◩ constipation (common cause but only occasionally presents)
◩◩ ectopic pregnancy (1/250 pregnancies)
◩◩ appendicitis (1/1000 pregnancies)
◩◩ red degeneration of fibroid
◩◩ torsion/rupture of ovarian cyst or tumour

RARE
◩◩ uterine rupture (in UK 1/1500 pregnancies, of which 70% due to Caesarian scar dehiscence)
◩◩ uterine torsion (axial rotation >90°): 90% associated with fibroids, adnexal masses and
anatomical uterine anomalies
◩◩ liver congestion due to pre-eclampsia
◩◩ rectus sheath haematoma

15
 16 Symptom Sorter

Ready reckoner
S. pubis strain Miscarriage Labour Abruption Pyelonephritis
Localised tenderness Yes No No Possible Yes
Crampy pain No Yes Yes No No
Vaginal bleeding No Yes No Yes No
Uterine rigidity No No No Yes No
Fever, unilateral pain No No No No Yes

Possible investigations
These will be dictated by the clinical urgency of the situation. In severe pain, they will be done
in secondary care.
LIKELY: Urinalysis, MSU.
POSSIBLE: Ultrasound, FBC.
SMALL PRINT: Laparoscopy.

◩◩ Urinalysis: Proteinuria in pre-eclampsia. Blood, pus cells and nitrite in urinary tract infection
(UTI); the infecting organism will be confirmed on MSU.
◩◩ FBC: Raised WCC in UTI.
◩◩ Imaging ultrasound can be diagnostic in abruption and miscarriage; the presence of an
intrauterine pregnancy makes an ectopic very unlikely; ultrasound may also be helpful in
detecting a rectus sheath haematoma.
◩◩ Laparoscopy: To confirm ectopic pregnancy.

TOP TIPS
◩◩ Pain on standing and walking, and relieved by rest, with exquisite pubic symphysis tenderness,
is ‘symphyseal pain’ – an often overlooked cause.
◩◩ Allay understandable anxieties as appropriate – particularly regarding the well-being of the
foetus or the possibility of premature labour.
◩◩ Do not be too ready to diagnose UTI on the basis of an abnormal urinalysis – contamination
in pregnancy is common.
 Acute abdominal pain in pregnancy 17

◩◩ Distortion of anatomy may alter symptoms and signs – appendicitis is notoriously difficult
to diagnose in the second trimester. If in doubt, admit.
◩◩ A woman in early pregnancy who experiences unilateral lower abdominal pain followed by
light bleeding or blackish discharge has an ectopic until proved otherwise.
◩◩ Don’t overlook the diagnosis of premature labour. Women with no previous experience of
labour pain might not consider this possibility.
◩◩ Placental abruption causes severe, continuous pain with a tender, hard uterus. Vaginal
bleeding may be minimal. Admit immediately.
◩◩ Don’t forget pre-eclampsia as a cause of epigastric pain in the third trimester – check the
blood pressure (BP) and urine.

NOTES:
CHRONIC/RECURRENT
ABDOMINAL PAIN
IN ADULTS

The GP overview
This problem may present in any age group. The causes in children are covered in another
section. In young to middle-aged adults, the cause is very likely to be benign, but this alters with
age: Malignancy should always be suspected in the elderly even though other causes are still
commoner. A precise diagnosis sometimes remains elusive.

Differential diagnosis
COMMON
◩◩ IBS
◩◩ recurrent UTI
◩◩ chronic peptic ulcer (PU)
◩◩ constipation
◩◩ diverticular disease

OCCASIONAL
◩◩ gallstones
◩◩ hydronephrosis
◩◩ post-herpetic neuralgia
◩◩ inflammatory bowel disease
◩◩ ureteric colic
◩◩ spinal arthritis
◩◩ coeliac disease (commoner than traditionally thought: 1 in 300 adults)

RARE
◩◩ mesenteric artery ischaemia (abdominal angina)
◩◩ chronic pancreatitis
◩◩ subacute obstruction (adhesions, malignancy and diverticulitis)
◩◩ functional (psychogenic) abdominal pain
◩◩ malignancy
◩◩ metabolic causes, e.g. Addison’s disease, porphyria, lead poisoning

18
 Chronic/recurrent abdominal pain in adults 19

Ready reckoner
IBS UTI PU Constipation Diverticulitis
High abdominal pain Possible No Yes Possible Possible
Colicky Yes No No Yes Yes
Weight loss No Possible Possible No No
Diarrhoea Yes No No Possible Yes
Rectal bleeding No No No Possible Possible

Possible investigations
LIKELY: Urinalysis, FBC, ESR/CRP, MSU, H. pylori testing.
POSSIBLE: U&E, LFT, amylase, coeliac screen, CA-125, FIT, faecal calprotectin, plain abdominal
X-ray, ultrasound, renal imaging, hospital-based lower GI investigations, gastroscopy.
SMALL PRINT: Specialised investigations such as mesenteric angiography and further tests for
rare medical causes.
◩◩ Urinalysis: Blood alone with stone; blood, pus cells and nitrite in UTI.
◩◩ MSU: To confirm urinary infection and guide treatment.
◩◩ FBC and ESR/CRP: May suggest inflammatory bowel disease, PU or malignancy. Raised
platelets associated with oesophageal or stomach cancer.
◩◩ U&E may be deranged in hydronephrosis, renal stones or Addison’s disease.
◩◩ LFT and amylase: LFT may be abnormal if carcinoma present. Amylase may be raised in
pancreatitis and bowel ischaemia.
◩◩ Coeliac screen: Anti-endomysial and anti-gliadin antibodies – suggest coeliac disease if
positive.
◩◩ CA-125: Especially in women aged 50 or more, may help exclude ovarian cancer.
◩◩ H. pylori testing: Strong association with peptic ulcer disease.
◩◩ FIT: A useful colorectal cancer ‘rule out’ test in those aged 50 and over.
◩◩ Faecal calprotectin: To help rule out inflammatory bowel disease, especially if recurrent or
persistent diarrhoea is also a feature.
◩◩ Plain abdominal X-ray: May reveal constipation, subacute obstruction or kidney stones.
◩◩ Renal imaging: For renal stones or recurrent UTI.
◩◩ Ultrasound: Will show hydronephrosis and gallstones. Pelvic/abdominal ultrasound also
indicated if CA-125 elevated.
◩◩ Hospital-based lower GI investigations: For various lower bowel disorders.
◩◩ Gastroscopy: May be required to confirm PU and exclude gastric carcinoma.
◩◩ Further tests such as angiography (for mesenteric ischaemia) or investigations for rare
medical causes may be arranged after specialist referral.
 20 Symptom Sorter

TOP TIPS
◩◩ Simply establishing what provokes or relieves the problem can provide helpful pointers – pain
occurring after eating suggests gallstones, PU, gastric carcinoma or mesenteric ischaemia; if
relieved by defecation, the likely diagnoses are IBS or constipation.
◩◩ In an otherwise well patient, the longer the history the less likely there is to be significant
underlying disease.
◩◩ Avoid repeated investigation if a patient has already been thoroughly assessed in the past –
unless the individual becomes unwell or develops new symptoms. Be frank with the patient
by explaining about the ‘law of diminishing returns’ in investigating chronic unexplained
abdominal pain.
◩◩ Be prepared to make a positive diagnosis of IBS in a fit young patient if the symptoms are
classical and basic investigations are negative; explanation and education are the keys to
effective management.

◩◩ Weight loss in association with recurrent abdominal pain suggests significant pathology.
◩◩ Hard enlarged left supraclavicular nodes (Troisier’s sign) are pathognomic of gastric
carcinoma.
◩◩ Beware that constipation itself is often a symptom rather than a diagnosis. Be sure to establish
and treat any underlying cause if it doesn’t respond to simple treatment.
◩◩ IBS is the commonest diagnosis – but consider other possibilities if the pain is always in
the same site, wakes the patient at night or is associated with rectal bleeding or weight loss.

NOTES:
CONSTIPATION

The GP overview
Constipation is defined as the infrequent or difficult evacuation of faeces. One study of a large
normal working population showed variation in frequency from three times a day to three times
a week. The average GP will see about 18 presentations of constipation each year. In most cases,
there is a combination of aetiological factors, and serious causes are rare.

Differential diagnosis
COMMON
◩◩ diet and lifestyle (inadequate fibre and ignoring the urge to defecate)
◩◩ inactivity (especially in the elderly)
◩◩ irritable bowel syndrome (IBS)
◩◩ painful perianal conditions: fissure, haemorrhoids, abscess, florid warts
◩◩ drugs, e.g. opiates, iron, aluminium hydroxide

OCCASIONAL
◩◩ poor fluid intake
◩◩ acquired megacolon, e.g. chronic laxative abuse, neurological problems, scleroderma
◩◩ diverticulosis (with or without stricture)
◩◩ hypothyroidism
◩◩ carcinoma of rectum or colon

RARE
◩◩ pressure from extracolonic pelvic masses
◩◩ acute bowel obstruction (various causes)
◩◩ hypercalcaemia
◩◩ Crohn’s disease with stricture
◩◩ infants and children: behavioural (‘stool holding’), Hirschsprung’s disease

21
 22 Symptom Sorter

Ready reckoner
Diet and lifestyle Inactivity IBS Perianal conditions Drugs
Likely in elderly Yes Yes No Possible Yes
‘Overflow’ diarrhoea Possible Yes No Possible Possible
Mucus PR No No Possible Possible No
Short history No No Possible Yes Possible
PR exam very painful No No No Yes No

Possible investigations
LIKELY: None; if suspicion of significant underlying bowel pathology, then FBC, FIT, hospital-
based lower GI investigations.
POSSIBLE: Urinalysis, thyroid function tests (TFT).
SMALL PRINT: Plain abdominal X-ray, serum calcium, ultrasound, CT scan, biopsy.

◩◩ Urinalysis: Specific gravity high if inadequate fluid intake.

◩◩ FBC: May reveal iron deficiency anaemia if underlying carcinoma.
◩◩ FIT: A useful colorectal cancer ‘rule out’ test in those aged 60 and under with change in
bowel habit such as constipation (over 60s likely to be referred regardless).
◩◩ TFT and serum calcium: Will reveal hypothyroidism or hypercalcaemia.
◩◩ Plain abdominal X-ray: May reveal megacolon full of faeces; erect and supine views will
show obstruction.
◩◩ Hospital-based lower GI investigations: May reveal carcinoma or diverticular disease.
◩◩ Ultrasound/CT scan: May be helpful if a pelvic mass is present.
◩◩ Biopsy: Of suspicious lesions or to confirm Hirschsprung’s disease.

TOP TIPS
◩◩ Clarify what patients mean by constipation – they often use the term inaccurately (e.g.
in reference to a perfectly ‘normal’ bowel habit or to describe another symptom such as
tenesmus).
◩◩ The longer the history, the less likely there is to be any underlying or remediable cause.
◩◩ Check the medication history (including over-the-counter treatment) – just about any
medication can alter the bowel habit.
◩◩ Look at the patient – your immediate impression may give important clues to the underlying
diagnosis (e.g. hypothyroidism or weight loss in malignancy).
◩◩ In children with constipation, continue treatment for weeks or even months to achieve easy
and pain-free bowel movements. Reassure parents that the use of laxatives does not lead to a
‘lazy bowel’ and that the constipation is not a sign of a ‘blockage’.
 Constipation 23

◩◩ Constipation alone in the elderly is rarely caused by sinister pathology – but if it is

accompanied by other significant symptoms, such as weight loss, rectal bleeding or mucus,
or diarrhoea, carcinoma is likely.
◩◩ Beware of attributing abdominal pain to constipation – the true diagnosis might be intestinal
obstruction. Visible peristalsis with audible borborygmi is never due to simple constipation.
◩◩ Cases of Hirschsprung’s disease can present ‘late’ – consider the diagnosis in a child with
chronic constipation, a persistently swollen abdomen and an empty rectum.
◩◩ Beware of assuming that known pathology (such as diverticular disease or IBS) in an
individual is the cause of constipation. If the patient has presented with constipation, then
there may have been a significant change in the pattern or the nature of the symptoms.

NOTES:
DIARRHOEA IN ADULTS

The GP overview
Diarrhoea is the passage of abnormally liquid and frequent stools. It is said to be chronic if it lasts
more than 2 weeks. It is the fifth-commonest presenting symptom in general practice. Patients
will use the term ‘diarrhoea’ when presenting, but they may just mean frequent stools.
NOTE: For diarrhoea in children, see separate section.

Differential diagnosis
COMMON
◩◩ acute infective gastroenteritis, e.g. rotavirus, Campylobacter, food poisoning
◩◩ antibiotics (and other drug side effects)
◩◩ irritable bowel syndrome (IBS)
◩◩ diverticulitis
◩◩ overflow constipation (especially in the elderly)

OCCASIONAL
◩◩ lactose intolerance
◩◩ chronic infection: Amoebiasis, giardiasis, hookworm
◩◩ bowel neoplasia
◩◩ inflammatory bowel disease (IBD): Ulcerative colitis and Crohn’s disease
◩◩ excess alcohol
◩◩ toddler diarrhoea
◩◩ coeliac disease

RARE
◩◩ HIV infection
◩◩ appendicitis
◩◩ laxative misuse
◩◩ thyrotoxicosis
◩◩ malabsorption, various causes
◩◩ allergy
◩◩ ovarian cancer

24
 Diarrhoea in adults 25

Ready reckoner
Gastroenteritis Antibiotics IBS Diverticulitis Overflow
Vomiting too Possible Possible No Possible No
Chronic or recurrent No No Yes Possible Yes
Constant severe pain No No No Yes No
Marked abdominal tenderness No No No Yes No
Blood in stool Possible Possible No Possible No

Possible investigations
LIKELY: If persistent, stool specimen, FBC, ESR/CRP, TFT, anti-endomysial and anti-gliadin
antibodies, faecal calprotectin.
POSSIBLE: Urinalysis, LFT, FIT, hospital-based lower GI investigations, CA-125.
SMALL PRINT: HIV test, tests for malabsorption.

◩◩ One stool sample is sufficient in acute diarrhoea of more than a week to look for common
infections.
◩◩ Series of three daily stool samples necessary to look for ova, cysts and parasites in chronic
diarrhoea.
◩◩ FBC: Hb may be reduced and ESR/CRP elevated in IBD and malignancy; iron deficiency
anaemia in neoplasia, coeliac disease; diverticulitis – check ferritin, B12 and folate too; WCC
raised in IBD and infection.
◩◩ TFT: Will reveal thyrotoxicosis.
◩◩ Anti-endomysial and anti-gliadin antibodies: Suggest coeliac disease if positive.
◩◩ Faecal calprotectin: Helps rule out inflammatory bowel disease.
◩◩ LFT: May suggest secondaries or alcoholism.
◩◩ FIT: A useful colorectal cancer ‘rule out’ test in those aged 60 and under with change in
bowel habit such as diarrhoea (over 60s likely to be referred regardless).
◩◩ Urinalysis: Specific gravity high in dehydration.
◩◩ Hospital-based lower GI investigations: Will confirm diagnosis of malignancy, diverticulosis,
carcinoma and IBD.
◩◩ CA-125: To help exclude ovarian cancer – especially in women aged 50 or more.
◩◩ HIV test: For HIV infection.
◩◩ Tests for malabsorption: Such as stool fat analysis, lactose tolerance test, small intestinal
biopsy (all secondary care).

TOP TIPS
◩◩ Clarify what patients mean by diarrhoea – they may be referring simply to a minor change
in their normal habit or the frequent passage of normal stools.
 26 Symptom Sorter

◩◩ Giardiasis is much more common than previously thought and may be difficult to isolate in
stool specimens. Empirical treatment is justified if the clinical picture is suggestive (recent
onset after travel of persistent fatty diarrhoea with anorexia, nausea and bloating).
◩◩ IBS rarely causes nocturnal diarrhoea.
◩◩ Patients with gastroenteritis should steadily improve after a few days, but may experience
symptoms for up to 10 days – warn them of this.
◩◩ Do not be caught out by overflow diarrhoea in the elderly. The only way to establish this
diagnosis is with a PR.
◩◩ Remember to ask about foreign travel and occupation, which have implications for diagnostic
possibilities and management.

◩◩ Weight loss in chronic diarrhoea is highly suggestive of significant pathology.

◩◩ In a young and otherwise well person, it is reasonable to make a positive clinical diagnosis of
irritable bowel syndrome with minimal investigation – but beware of making this diagnosis
for the first time in the middle-aged and elderly. Significant pathology mimicking IBS is
likely.
◩◩ Initial telephone consultation is sufficient for most cases of acute diarrhoea, but if in constant
(not colicky) abdominal pain, always see and examine to exclude an acute surgical condition.
◩◩ Remember that acute diarrhoea in the elderly can precipitate or aggravate renal failure –
especially if they are on ACE inhibitors. Stop these drugs for the duration of the illness and
ensure adequate hydration.

NOTES:
DIARRHOEA IN
CHILDREN

The GP overview
This is a very common ‘day duty’ presentation and is usually caused by gastroenteritis or some
other acute infection. Less common is the subacute or prolonged case, where the differential is
wider and where a more detailed analysis is required.

Differential diagnosis
COMMON
◩◩ gastroenteritis
◩◩ other systemic infection (e.g. UTI, otitis media, pneumonia)
◩◩ toddler’s diarrhoea
◩◩ medication side effects (usually antibiotics)
◩◩ cow’s milk protein intolerance (CMPI)

OCCASIONAL
◩◩ lactose intolerance (typically following a bout of gastroenteritis in babies)
◩◩ faecal impaction (causing overflow diarrhoea)
◩◩ irritable bowel syndrome
◩◩ coeliac disease
◩◩ other gastrointestinal infections, e.g. giardia

RARE
◩◩ inflammatory bowel disease (IBD)
◩◩ appendicitis (relatively common but rarely presents with diarrhoea)
◩◩ intussusception
◩◩ cystic fibrosis

27
 28 Symptom Sorter

Ready reckoner
Gastroenteritis Other systemic Toddler’s Medication CMPI
infection diarrhoea side effects
Blood in diarrhoea Possible No No No Possible
Recent or current antibiotics No Possible No Yes No
Fever Possible Possible No Possible No
Lasts more than 2 weeks Possible No Yes Possible Yes
Other localising symptoms No Yes No Possible No
(e.g. respiratory, urinary or ear)

Possible investigations
LIKELY: None.
POSSIBLE:Stool culture, urinalysis, MSU, FBC, CRP, ESR, anti-endomysial and anti-gliadin
antibodies, faecal calprotectin.
SMALL PRINT: Hospital-based tests (e.g. for cystic fibrosis, IBD and to confirm coeliac disease).

◩◩ Stool culture: For microbiological examination if the diarrhoea persists more than a week,
is bloody or there is relevant recent foreign travel; send three specimens for ova, cysts and
parasites if giardia suspected.
◩◩ Urinalysis: May help if a UTI is suspected as the underlying cause.
◩◩ MSU: For confirmation of a suspected UTI.
◩◩ FBC, ESR, CRP: Hb may be reduced, and CRP/ESR raised in IBD.
◩◩ Anti-endomysial and anti-gliadin antibodies: If coeliac is a possibility.
◩◩ Faecal calprotectin: To help rule out IBD if diarrhoea is prolonged.
◩◩ Hospital-based tests: These might include endoscopy and biopsy in suspected IBD or coeliac
disease, and tests for possible cystic fibrosis.

TOP TIPS
◩◩ It is not unusual for the diarrhoea in gastroenteritis to take a couple of weeks to settle;
consider a stool specimen if it is not starting to improve after a week.
◩◩ Don’t overlook faecal impaction as a cause of overflow diarrhoea in children, the clues being
soiling and a preceding history of constipation.
◩◩ Lactose intolerance tends to be over-diagnosed and often confused with CMPI. The former
is less common, typically follows gastroenteritis and is usually short lived.
◩◩ Undigested food (‘peas and carrots syndrome’) in the persistent loose stool of an otherwise
well and thriving child is virtually pathognomic of the harmless toddler’s diarrhoea.
 Diarrhoea in children 29

◩◩ In the acute case – particularly in younger children with severe diarrhoea and associated
vomiting – assess for dehydration as a priority. If the child is significantly dehydrated, then
admission will be needed regardless of cause.
◩◩ Bloody diarrhoea raises the stakes somewhat. In the acute situation, this could be one of the
more severe forms of gastroenteritis or, especially in those under 1 year of age, intussusception.
In more prolonged cases, it might indicate CMPI or IBD.
◩◩ Very minor, transient weight loss is common during a bout of gastroenteritis. More prolonged
weight loss with persistent diarrhoea should, on the other hand, prompt urgent referral.
◩◩ Remember that appendicitis can cause diarrhoea. In such cases, the abdominal pain is usually
more marked and constant than in a typical gastroenteritis, where it is typically mild (and
therefore not the presenting complaint) and intermittent.

NOTES:
EPIGASTRIC PAIN

The GP overview
Up to 40% of the adult population suffer this symptom in any 1 year. Only about one in ten
seek help from their GP, usually presenting with ‘indigestion’. The first step involves sorting out
exactly what the patient means by this term. The second is to establish whether it is acute, chronic
or acute-on-chronic. And the third revolves around management, which is often orientated
towards a pragmatic, symptomatic approach rather than establishing a precise diagnosis.

Differential diagnosis
COMMON
◩◩ non ulcer dyspepsia (NUD)
◩◩ gastro-oesophageal reflux disease (GORD)/gastritis
◩◩ IBS
◩◩ gallstones
◩◩ duodenal ulcer/duodenitis

OCCASIONAL
◩◩ drug related, e.g. antibiotics, NSAIDs, bisphosphonates
◩◩ pancreatitis (acute or chronic)
◩◩ muscular
◩◩ peritonitis (perforated DU or carcinoma)
◩◩ carcinoma of the stomach
◩◩ gastric ulcer
◩◩ oesophageal spasm
◩◩ aerophagy

RARE
◩◩ angina or myocardial infarct
◩◩ pneumonia
◩◩ carcinoma of the pancreas
◩◩ ruptured abdominal aortic aneurysm
◩◩ gastrointestinal obstruction
◩◩ referred from spine
◩◩ epigastric hernia

30
 Epigastric pain 31

Ready reckoner
NUD GORD/gastritis IBS Gallstones DU/duodenitis
Nocturnal pain Possible Possible No Possible Yes
Relief with antacids Possible Yes No No Possible
Stress related Possible Possible Yes No Possible
Radiates to back No No No Possible Possible
Vomiting No No No Possible Possible

Possible investigations
LIKELY: FBC, H. pylori testing.
POSSIBLE: LFT, upper GI endoscopy, ultrasound.
SMALL PRINT: Serum amylase, barium swallow or meal, oesophageal manometry/pH studies,
cardiac biomarkers, ECG, CXR, erect and supine abdominal X-rays, further hospital-based
upper GI investigations.
◩◩ FBC: Anaemia in underlying malignancy or bleeding from peptic ulcer; WCC raised in
cholecystitis and pancreatitis. Raised platelets associated with oesophageal or stomach
cancer.
◩◩ H. pylori testing: Strong association with peptic ulcer disease; possibly also with other
gastrointestinal pathologies.
◩◩ LFT: May be abnormal in gallstones or malignancy.
◩◩ Upper GI endoscopy: To visualise/biopsy the upper GI tract (in particular, to exclude
carcinoma of the stomach).
◩◩ Ultrasound: For gallstones; may reveal other pathology such as pancreatic disease.
◩◩ Barium swallow or meal: For investigation of the oesophagus, stomach and duodenum in
those unwilling to have, or unfit for, endoscopy.
◩◩ Serum amylase: Elevated in acute pancreatitis.
◩◩ Other tests: Most of these are likely to be initiated in secondary care after referral. They
include oesophageal manometry/pH studies (if likely oesophageal problem but a normal
endoscopy), cardiac biomarkers and ECG (possible acute cardiac event), CXR (pneumonia),
erect and supine abdominal X-rays (obstruction), CT or MRI scan if a mass is suspected or
symptoms remain unexplained.

TOP TIPS
◩◩ It’s important to address underlying concerns. Most patients with epigastric pain do not seek
medical help. Those that do usually fear significant disease such as cancer.
◩◩ A diagnosis of peptic ulcer still frightens many patients, especially older age groups, as
they may be unaware of recent therapeutic advances. Provide adequate explanation and
reassurance.
 32 Symptom Sorter

◩◩ Don’t overlook the medication history, as this may provide a simple solution to the problem.
◩◩ A normal endoscopy does not rule out oesophageal problems such as GORD or spasm.
◩◩ Cardiac pain can sometimes be epigastric. If suspecting angina, beware that a trial of GTN
can help or confuse – as it also eases oesophageal spasm.

◩◩ Guidance on who to refer urgently to exclude carcinoma, and for what, can be complex and
confusing. Some degree of judgement is required, but certainly patients aged 55 or more with
unexplained dyspepsia and weight loss need urgent referral, as do patients with dysphagia.
◩◩ In an obviously unwell patient with weight loss and epigastric pain, do not be ‘reassured’ by
a normal endoscopy. There may well still be significant pathology such as carcinoma of the
pancreas.
◩◩ In at least 50% of cases, carcinoma of the pancreas presents with epigastric pain rather than
the classical painless, progressive jaundice.
◩◩ In acute cases, do not overlook referred pain – from heart, lungs or spine.

NOTES:
LOIN PAIN

The GP overview
Doctors may disagree – with patients and among themselves – about where exactly the ‘loin’ is.
For the purposes of this chapter, it is the area between the lower ribs and the pelvis, anteriorly
or posteriorly. Loin pain is a common acute or subacute presentation, with patients tending to
assume that the symptom inevitably represents a renal problem. Occasionally, they are correct.
But a musculoskeletal aetiology is much more likely, and there are other possible causes to trip
up the unwary.

Differential diagnosis
COMMON
◩◩ acute musculoskeletal pain
◩◩ renal or ureteric stone
◩◩ acute pyelonephritis
◩◩ rib pain
◩◩ shingles

OCCASIONAL
◩◩ gynaecological causes (e.g. ectopic pregnancy, PID, ruptured or torted ovarian cyst)
◩◩ gastrointestinal causes (e.g. appendicitis, biliary colic)
◩◩ other urological causes in men (e.g. epididymitis, prostatitis)
◩◩ pelvi-ureteric obstruction
◩◩ radicular pain (e.g. from osteoarthritis or disc prolapse)

RARE
◩◩ leaking abdominal aortic aneurysm
◩◩ retroperitoneal fibrosis
◩◩ renal infarction
◩◩ renal tumour (either directly or by causing a blood clot in the ureter)
◩◩ acute papillary necrosis
◩◩ factitious (e.g. addicts seeking opioids)
◩◩ idiopathic loin pain haematuria syndrome

33
 34 Symptom Sorter

Ready reckoner
Acute musculoskeletal Renal or Acute Rib pain Shingles
pain ureteric stone pyelonephritis
Urinary symptoms No Possible Possible No No
Fever No Possible Yes No Possible
Macro or microscopic No Possible Possible No No
haematuria
Pain worse with Yes No No Possible No
movement
Pain colicky No Yes No No No

Possible investigations
LIKELY: Urinalysis, MSU.
POSSIBLE: U&E, sieving urine, renal imaging.
SMALL PRINT: Metabolic screen (usually secondary care); other hospital-based investigations.

◩◩ Urinalysis: The presence of microscopic haematuria would support your diagnosis of renal/
ureteric colic (though its absence does not rule it out); urinalysis may also reveal evidence of
urinary infection or acute papillary necrosis (blood and white cells in the latter).
◩◩ MSU: To confirm suspected infection; also might suggest acute papillary necrosis (blood
and sterile pyuria).
◩◩ U&E: To assess renal function when underlying renal issue suspected.
◩◩ Sieving urine: To retrieve stone in renal/ureteric colic for subsequent analysis.
◩◩ Renal imaging: Non-contrast helical CT is the hospital investigation of choice in suspected
renal/ureteric colic; depending on how acute the presentation is, and on local pathways and
guidelines, plain abdominal X-ray or US may be helpful. Renal imaging may also be required
in acute pyelonephritis (especially if recurrent), possible renal tumour and in suspected
pelvi-ureteric obstruction. Ultrasound, IVU, CT or MRI may be needed to diagnose
retroperitoneal fibrosis.
◩◩ Metabolic screen such as blood and 24 hour urine for calcium, phosphate and urate in stone
formers.
◩◩ Other hospital-based investigations: Required to clarify the diagnosis in those admitted,
and will depend on whether the cause seems urological, gynaecological or gastrointestinal.

TOP TIPS
◩◩ Remember that many patients fear kidney problems. They may value reassurance that all is
well renally as much as your positive diagnosis of musculoskeletal pain.
◩◩ Take care during busy telephone triaging sessions – be sure to check that the apparently
simple case of cystitis isn’t actually a developing case of acute pyelonephritis.
 Loin pain 35

◩◩ The absence of microscopic haematuria does not rule out renal/ureteric colic but should
certainly prompt a consideration of alternative diagnoses.
◩◩ Patients with genuine renal/ureteric colic tend to writhe about in pain.
◩◩ Think of shingles, particularly in elderly patients with an otherwise unexplained short
history of burning loin pain, and warn them of the possibility of a rash developing – the
pain may precede the skin manifestations by a few days.

◩◩ Beware of a first diagnosis of renal/ureteric colic (especially left sided) in older men – a
leaking abdominal aortic aneurysm can cause very similar symptoms.
◩◩ Some cases of renal/ureteric colic can be managed – at least initially – in the community.
But those with fever, prolonged or unresponsive pain, or known renal compromise should
be admitted.
◩◩ Remember that acute pyelonephritis in men and children, and recurrent episodes in women,
require investigation to exclude any underlying urological problem.
◩◩ Be cautious about using strong analgesics for possible renal/ureteric colic in patients with
past histories of drug addiction – this used to be a favoured way of engineering a free opioid
fix, although the increasing use of diclofenac as the urgent treatment of choice has reduced
this problem.

NOTES:
RECURRENT
CHILDHOOD
ABDOMINAL PAIN

The GP overview
Recurrent abdominal pain in childhood can be a calling card for a myriad hidden agendas.
More than 85 causes have been listed, and as in most areas of general practice, the trick is to sift
through the morass of information to find the keys to the diagnosis and open the way to effective
management. The underlying cause in the most persistent cases is usually non-organic (90% of
those referred to hospital).

Differential diagnosis
COMMON
◩◩ recurrent viral illnesses
◩◩ anxiety and depression (sometimes known as periodic syndrome or abdominal migraine)
◩◩ recurrent UTI
◩◩ constipation
◩◩ gastritis and GORD

OCCASIONAL
◩◩ infant colic (which is assumed to cause abdominal pain)
◩◩ cow’s milk protein intolerance (in infants)
◩◩ Crohn’s and coeliac disease
◩◩ duodenal ulcer (DU)
◩◩ irritable bowel syndrome
◩◩ diabetes mellitus
◩◩ Henoch–Schönlein purpura
◩◩ hydronephrosis, renal stones and ureteric reflux
◩◩ Meckel’s diverticulum

RARE
◩◩ parasitic infestation of the gut
◩◩ food allergy
◩◩ sickle-cell disease

36
 Recurrent childhood abdominal pain 37

◩◩ tuberculosis (TB)
◩◩ Hirschsprung’s disease
◩◩ temporal lobe epilepsy
◩◩ pica

Ready reckoner
Recurrent Anxiety/ Recurrent Constipation Gastritis/
viral illness depression UTI GORD
School/home stress No Yes No No No
Related to eating No No No Possible Possible
Diarrhoea Possible Possible No Possible No
Fever Yes No Yes No No
Abnormal urinalysis Possible No Yes No No

Possible investigations
LIKELY: Urinalysis, MSU.
POSSIBLE: FBC, blood film, ESR/CRP, anti-endomysial and anti-gliadin antibodies.
SMALL PRINT: Faecal calprotectin, plain abdominal X-ray, abdominal ultrasound, further
hospital-based investigations (after referral).
◩◩ Urinalysis and MSU: Urinalysis will reveal evidence of a UTI, which will be confirmed
with an MSU for microscopy and culture. Urinalysis will also reveal glucose in diabetes and
possible haematuria in Henoch–Schönlein purpura.
◩◩ FBC: Hb may be reduced in any chronic disorder; leucocytosis in bacterial infection;
eosinophilia in parasitic infestation or genuine food allergy. Blood film may show sickling.
Raised ESR/CRP suggests organic disease.
◩◩ Anti-endomysial and anti-gliadin antibodies: A positive result suggests coeliac disease.
◩◩ Faecal calprotectin: If Crohn’s suspected.
◩◩ Ultrasound: Non-invasive first line investigation of renal tract. Other investigation for
confirmed UTI will be arranged by the paediatrician.
◩◩ Further hospital-based investigations: If there is a high suspicion of organic disease, e.g.
endoscopy for DU, barium meal and follow-through for Crohn’s disease.

TOP TIPS
◩◩ The majority of children with recurrent abdominal pain will not have organic pathology –
take the problem seriously and assess carefully, but avoid reinforcing worries with unnecessary
investigation or referral.
 38 Symptom Sorter

◩◩ Explore the parents’ concerns – a child’s anxiety may be fed by parents unnecessarily
worrying about sinister and unlikely diagnoses.
◩◩ Talk to children alone – this may reveal relevant problems at home or school which they
would not have been able to admit in front of parents.
◩◩ If recurrent UTI is a possibility, provide the parents with the necessary bottle and lab form
so that an MSU can be taken during the next episode of pain.
◩◩ Infants with perceived abdominal pain are often taken to various doctors and/or A&E. They
may well end up with diagnoses of GORD, cow’s milk protein intolerance, infant colic or
some combination of these. It may take trials of treatment to ease the problem (which is
likely to resolve on its own given time anyway). But if the infant is otherwise unwell or not
thriving, it should be referred promptly for a paediatric opinion.

◩◩ Organic disease is suggested by pain distant from the umbilicus which wakes the child and
which is associated with loss of appetite or weight, or a change in bowel habit.
◩◩ Beware the unlikely event of an acute cause for the pain supervening, e.g. appendicitis,
torsion of the testis – ensure that parents know that a different, acute pain should not be
dismissed as ‘the same old problem’, but should be presented urgently.
◩◩ Children proven to have a UTI should be managed according to NICE guidelines.
◩◩ Avoid colluding in parental somatisation and overlooking the existence of family dysfunction
or other causes of unhappiness.
◩◩ Don’t forget the rare possibility of sickling in the appropriate ethnic groups.

NOTES: